u-world mental health nclex questions
A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam. The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse? 1. ECT is safe and your spouse will not feel anything 2. It could take up to 3 weeks for medication to become effective 3. Your spouse could die by not receiving this treatment 4. Your spouse is very ill and ECT might be the best treatment at this time. What are your concerns about ECT?
A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam. The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse?
The nurse in a psychiatric clinic is evaluating the client's response to treatment for somatic symptom disorder with cardiac manifestations. Which client statement indicates a need for further treatment? 1. "I am looking for another heart specialist to evaluate my symptoms." 2. "I asked my spouse for support while I deal with my mother's death." 3. "I have started carrying a sketchbook to draw in when I am stressed." 4. "I journal daily about my stress level and any heart-related symptoms."
Answer: 1 Somatic symptom disorder (SSD) is a psychological disorder in response to stress that results in symptoms of physical disorders (eg, chest pain, syncope) for which there is no identifiable medical source (eg, myocardial infarction, hypotension). Periods of increased stress (eg, work demands, family events) frequently precede the onset, or worsening, of physical symptoms and result in frequent requests for medical attention and treatment. SSD and care-seeking behaviors may then be reinforced and perpetuated by secondary gains (eg, social affirmation, "sick role," avoidance of unpleasant activities). When evaluating clients' responses to treatment for SSD, the nurse should monitor for the following indicators of positive progress: - Identification of alternate support systems for stress (eg, spouse, friends) (Option 2) - Identification of perceived benefits (ie, secondary gains) of behaviors - Use of stress-reducing strategies (eg, drawing, meditating) rather than fixation on symptoms (Option 3) - Verbalization of factors causing or worsening symptoms (Option 4) (Option 1) When medical treatment does not support a diagnosis for the physical symptoms, the client may become frustrated and seek the opinion of additional health care providers. This indicates a lack of treatment progress. Educational objective: Somatic symptom disorder (SSD) occurs when psychological stresses manifest as physical symptoms of illness without physiological cause. Treatment has been effective if the client with SSD is able to identify alternate support systems for stress, identify perceived benefits of behaviors, employ stress management strategies, and verbalize factors associated with symptoms. Additional Information Psychosocial Integrity NCSBN Client Need
The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior? 1. During 1-2 hours after each meal 2. During every meal 3. During the evening meal 4. During the overnight hours
Answer: 1 The eating behavior of a client with bulimia nervosa typically consists of binge eating followed by an inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives. Although it is important to provide one-on-one supervision to a client with bulimia during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting (Option 2). Clients with bulimia nervosa will often go to extreme lengths to engage in purging activity, especially at the beginning of a treatment program, as a way of gaining control. After mealtime, it may be necessary to restrict clients to the dayroom or a specified area with no bathroom privileges for a set period. Clients will also need to be monitored at all times for engaging in excessive exercise. (Option 3) Clients need to be monitored during every meal, not just during the evening meal. (Option 4) Secretive bingeing and purging during the night or before bedtime are not uncommon for a client with bulimia nervosa. However, in a structured inpatient environment, the client would not have access to excessive amounts of food. Educational objective: Clients with bulimia nervosa should be supervised during every meal. However, it is most important to monitor the postprandial activity of these clients to prevent self-induced vomiting as a way to prevent weight gain.
A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client? 1. Complete blood count and absolute neutrophil count 2. ECG and blood pressure 3. FAsting blood glucose and fasting lipid panel 4. Height, weight, and waist circumference
Answer: 1 Clozapine (Clozaril) is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis (a potentially fatal blood disorder causing a dangerously low WBC count) and is therefore used only in clients with treatment-resistant schizophrenia. A client must have a WBC count of ≥3500/mm3 (3.5 × 109/L) and an absolute neutrophil count (ANC) of ≥2000/mm3 (2 × 109/L) before starting clozapine, so it is critical to obtain a baseline complete blood count and ANC. Because agranulocytosis is reversible if caught early, the client's WBC count and ANC must also be monitored regularly throughout the course of clozapine therapy (initially once a week) (Option 1). Clients should also contact the health care provider immediately if they develop fever or sore throat, which can indicate infection due to neutropenia. (Option 2) ECG and blood pressure monitoring is performed before therapy initiation and periodically during therapy because prolonged QT interval and orthostatic hypotension are potential side effects of clozapine; however, agranulocytosis poses a more significant danger to the client. (Options 3 and 4) Hyperglycemia, dyslipidemia, and weight gain are potential side effects of clozapine therapy but are not as serious as agranulocytosis. Educational objective: Agranulocytosis, a serious adverse effect of clozapine, is potentially fatal. Pretreatment assessment and ongoing monitoring of WBC and absolute neutrophil counts are critical. Clients should contact the health care provider if they develop fever or sore throat, which can indicate infection due to neutropenia.
A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss? 1. I have signed up to be a dog walker when I normally would watch television 2. I understand that losing weight would improve my health and well-being 3. I want to lose 8 pounds (3.6 kg) so that my formal gown will fir in 4 weeks 4. My spouse and children are always encouraging me to eat healthier
Answer: 1 Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and motivation to change, which can be assessed using the Stages of Change Model. With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next: - Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy eating) (Option 4). - Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile (Option 2). - Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg, fitting into a dress) (Option 3). - Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television) (Option 1). - Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse. - Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is always possible. Educational objective: Successful behavior modification requires client readiness and motivation to change, as evidenced by the client developing and acting on a plan. Clients often do not initially see the need for change, but with the appropriate support they begin contemplating change, preparing to change (eg, goal setting), and then actively changing.
A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. The client can state the name and address but has no recollection of the past 2 days. What is the priority nursing action? 1. Assess vital signs 2. Contact family members 3. Encourage the client to recall recent events 4. Perform a mental status assessment
Answer: 1 This client is experiencing amnesia of undetermined origin. The cause could stem from a medical condition, substance abuse, traumatic brain injury, cognitive disorder such as dementia, or psychiatric condition such as dissociative fugue. Regardless of the diagnosis, the priority nursing action is to assess the client's physical status. This client has been wandering for 2 days and cannot recall previous locations, arriving at the present location, and the timetable involved. It is highly probable that the client is dehydrated and fatigued. It is most important to assess the client's physical needs and implement interventions to stabilize the physiologic condition before assessing psychosocial status and needs. (Option 2) It is appropriate to contact this client's family members. However, this is not the priority nursing action. (Option 3) This client may never be able to remember the events of the past 2 days. Encouraging a client to remember something when there is no sign of recollection may only increase client frustration. (Option 4) A mental status examination is an important component of the nurse's assessment. However, it is not the priority assessment. Educational objective: Assessment of a client's physiologic status and needs is the priority nursing action when the client is suffering from amnesia with no recollection of where he has been or what he has been doing for a period of time. Interventions need to be implemented to stabilize the client physically before psychosocial needs are addressed. Additional Information Reduction of Risk Potential NCSBN Client Need
The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply. 1. Client breaks eye contact when discussing caregiver 2. Client has lost 8 lb (3.63) in the previous weeks 3. Client is wearing clothing that is out of style 4. Client's eyeglasses have been visibly broken for 1 month 5. Client's prescription medication is expired
Answer: 1, 2, 4, 5 Elder abuse or neglect occurs when caregivers intentionally or unintentionally fail to meet the older adult client's physical, emotional, or social needs. Approximately 1 in 10 older adult clients are victims of physical, psychological, or sexual abuse by a caregiver. Commonly neglected necessities include water, food, medication, hygiene, and clothing. The client's living conditions may be unsafe or have inadequate access to public utilities. Objective findings consistent with abuse or neglect include: - Dehydration, malnutrition, and weight loss (Option 2) - Poor hygiene, soiled bedding or clothing, and pressure ulcers - Missing/broken assistive devices (eg, eyeglasses); medications withheld or expired (Options 4 and 5) Clients who have experienced abuse or neglect may find the situation difficult to discuss and display apprehension, restlessness, withdrawal, poor eye contact, shame, and despair (Option 1). The client may also deny or minimize the extent of the abuse out of fear or embarrassment. (Option 3) Clothing that is out of style is not indicative of neglect. However, soiled clothing or clothing unsuitable for the weather (eg, no jacket on a cold day) does indicate possible neglect. Educational objective: Manifestations of abuse or neglect in an older adult may include development of pressure ulcers, poor hygiene, dehydration, malnutrition, weight loss, soiled bedding/clothing, missing/broken assistive devices, and missing or expired medications.
Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply. 1. Assign the client to a private room 2. Choose clothing for the client 3. Have the client be in charge of planning an outing for the unit 4. Have the client join other client in the dining room for meals 5. Have the client participate in physical exercise with a staff member 6. Include the client in group therapy sessions
Answer: 1, 2, 5 In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is characterized by the following: - Excessive psychomotor activity - Euphoric mood - Poor impulse control - Flight of ideas, non-stop talking - Poor attention span, distractibility - Hallucinations and delusions - Insomnia - Wearing bizarre or inappropriate clothing, jewelry, and makeup - Neglected hygiene and inadequate nutritional intake - The care plan for a client experiencing an acute manic episode includes the following: Reduction of environmental stimuli - Providing a quiet, calm environment - Limiting the number of people who come in contact with the client - One-on-one interactions rather than group activities - Low lighting - A structured schedule of activities to help the client stay focused - Physical activities to help relieve excess energy - Providing high-protein, high-calorie meals and snacks that are easy to eat - Setting limits on behavior (Option 3) The client is easily distractible and would not be able to focus on planning an activity. (Option 4) The client who is experiencing an acute manic episode needs reduced environmental stimuli. Eating with other clients in the dining room would be too stimulating and could exacerbate psychomotor activity. (Option 6) The client with acute mania is not ready to participate in group activities. Educational objective: The nursing care plan for clients with acute mania includes providing a quiet, structured, non-stimulating environment; engaging the client in one-on-one activities and physical activity; limiting contact with other people; and providing foods of high nutritional value that are easy to eat.
The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply. 1. "How would you describe you child's usual behavior at home." 2. "These bruises seem excessive and suspicious. How did they happen?" 3. "What forms of discipline do you use with your child?" 4. "When you are stressed, what coping mechanisms do you use?" 5. "Who watches your child when you are at work?"
Answer: 1, 3, 4, 5 When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned, and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse. If possible, the interview should be done without the child present. The nurse should remain supportive and empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence." Open-ended questions are less threatening and provide more detailed responses. Information to gather includes: - Caregiver's perspective on the child's behavior (Option 1) - Methods of discipline used with the child (Option 3) - Routine caregivers for the child - Caregiver stress, coping, and support systems (Option 4) - Person or persons who care for the child when regular caregivers are away (Option 5) (Option 2) Use of the words "excessive" and "suspicious" to describe the child's bruising conveys judgment. This may cause the caregiver to become defensive and limit the nurse's ability to establish trust and find the source of the abuse. Educational objective: When child abuse is suspected, the nurse should convey empathy and support when questioning a caregiver while maintaining a nonjudgmental, nonthreatening attitude. Open-ended questions are less threatening and provide more detailed responses.
The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take? 1. Administer a PRN dose of methylphenidate 2. Ask the child t blow up a balloon 3. Give the child a "time out" in quiet place 4. Reinforce the consequences of disruptive behaviors
Answer: 2 A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however, some children with ADHD behave aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands and challenges. An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow, deep breaths relaxes the body, slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a balloon provides an easy mode of distraction and engages the child in a deep breathing exercise. After the child is calm, the nurse and the child can further discuss the disruptive behavior. Nursing interventions include the following: Stay calm and remove the child from the source of frustration/anger Assist the child in calming down with deep breathing exercises Discuss what precipitated the behavior and why the behavior is wrong Discuss acceptable ways of expressing anger and frustration Acknowledge that controlling anger is difficult Provide rewards for appropriate behavior Discuss the consequences of inappropriate behavior (Option 1) Methylphenidate is not used on a PRN basis; it is administered daily in 2-3 divided doses (or in sustained release form) 30-45 minutes before meals. (Option 3) Isolating the child is punitive and not therapeutic; instead, remove the child from the source of anger. (Option 4) Reminding the child of the consequences of inappropriate behavior is a valid intervention. However, the best action is to help the child calm down and relax first. Educational objective:The priority intervention for a child with ADHD who is engaging in aggressive behavior is to assist the child in calming down and gaining control. Deep breathing exercises are an easy and efficient approach to help the body and mind slow down and relax.
The nurse on the mental health unit received report on 4 clients. Which client should the nurse see first? 1. Client diagnosed with major depressive disorder who has consumed no food from the past 3 meal trays 2. Client with post traumatic disorder who reports an anxiety level of 8/10 and is pacing in the room 3. Client newly admitted with bipolar mania who reports sleeping only 4 hours last night 4. Client newly admitted with obsessive-compulsive disorder who has spent the last hour counting socks
Answer: 2 Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). Symptoms of PTSD include re-experiencing the traumatic event via flashbacks, nightmares, and feelings of distress in reaction to reminders; avoiding reminders of the trauma (eg, places, activities, thoughts, other triggers); and increased anxiety and emotional arousal (eg, insomnia, hypervigilance, outbursts of rage, irritability). Clients with an anxiety level of 8/10 and pacing behavior are demonstrating distress and require immediate attention as they might harm themselves or others. (Option 1) Clients with major depressive disorder frequently demonstrate loss of appetite, weight loss, and insomnia (typical depression). Some with atypical depression will experience increased appetite, weight gain, and hypersomnia. This client's lack of appetite needs to be addressed but is not the priority at this time. (Option 3) Clients experiencing acute mania have a decreased need for sleep and boundless energy; they often do not sleep for days. This is an expected behavior in a client newly admitted with a manic episode. As the client's manic episode is resolved via medications and therapy, sleep patterns will improve. (Option 4) Clients with obsessive-compulsive disorder perform compulsive behaviors (rituals) to decrease their level of anxiety. When newly admitted, the client should be given time to perform the rituals to avoid causing panic anxiety. Treatment will focus on assisting the client to develop better coping behaviors and gradually reduce the time spent on the ritualistic behavior. Educational objective: Clients with post-traumatic stress disorder have periods of extreme anxiety and emotional arousal during which they can be a danger to themselves or others.
A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action? 1. Encouraging visits by friends to decrease social isolation 2. Giving the client a schedule of daily activities 3. Placing the client in restraints during invasive procedures 4. Providing the client with a variety of toys
Answer: 2 A structured routine and consistency during hospitalization are critical in the care of clients with autism spectrum disorder (ASD). The nurse should talk with the parent and/or caregiver to determine the client's usual patterns and habits for a typical day at home, including meal times, bath time, and play time. In the unfamiliar and often unpredictable environment of the acute care setting, a schedule of activities can decrease anxiety and help the client with ASD anticipate what will happen next. (Option 1) A common nursing diagnosis associated with ASD is impaired social interaction characterized by unresponsiveness to people. Limiting the number of visitors can help avoid client overstimulation and facilitate a trusting relationship with the caregiver. (Option 3) Invasive procedures may be particularly difficult and painful for clients with ASD due to their hypersensitivity to touch. Strategies such as distraction and being held by parents or caregivers are preferred over the use of restraints. (Option 4) The young client with ASD may be overwhelmed and overstimulated if given too many choices. The best approach is for family members to bring in some of the client's favorite toys. Educational objective: Structure and consistency are crucial when caring for a client with autism spectrum disorder. A daily schedule of activities can decrease anxiety and help the client anticipate what will happen next. Limiting the number of visitors and choices can help avoid overstimulation and enhance communication with the caregiver.
The emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply. 1. Client has been sleeping on the floor in the den rather than the bed 2. Client has refused food and water for 4 days and has poor skin turgor 3. Client repeatedly mumbles, "I must kill them before they get me" 4. Marijuana was found in the client's personal belongings 5. The health care provider makes a diagnosis of schizophrenia
Answer: 2 & 3 Clients have the right to refuse hospital admission and treatment. However, all states and provinces have laws and procedures for involuntary admission that require clients to receive inpatient treatment for a psychiatric disorder against their will. The legal criteria for involuntary admission include: - The individual appears to be an imminent danger to self or others (Option 3). - The individual has a grave disability (ie, is unable to adequately care for basic needs [food, clothing, shelter, medical care, personal safety]) as a result of a mental illness (Option 2). Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner. Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that judgment and insight in deciding to refuse treatment are markedly impaired. (Option 1) Sleeping on the floor may be outside the client's normal behavior but does not meet the criteria for involuntary admission. (Option 4) Possession of marijuana does not meet the criteria for involuntary admission. (Option 5) The diagnosis of a mental illness alone does not justify the need for involuntary commitment. Educational objective: Clients with a mental illness have the right to refuse treatment, including inpatient hospitalization. Clients can be involuntarily admitted for psychiatric treatment if they pose an imminent danger to themselves or others or if they are gravely disabled and unable to meet their own basic needs.
A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? Select all that apply. 1. Explore the meaning behind the client's delusions 2. Focus on reality and verbally reinforce it 3. Focus on the client's feelings secondary to the delusions 4. Gently confront the client about the false beliefs 5. Present logical explanations to discredit the delusions
Answer: 2, 3 Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to understand them and the nurse-client relationship grows (Option 3). Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions (Option 2). For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real." (Option 1) Attempting to explore the meaning behind a delusion will encourage the client to focus/think more on this delusion. (Option 4) Confronting the client about the delusion is not therapeutic because arguing will not eradicate the delusion. It also hinders the development of a trusting nurse-client relationship. (Option 5) Clients believe that their delusions are real despite proof otherwise. Presenting logical explanations to discredit the delusions will not help. Educational objective: When communicating with a delusional client, the nurse must focus on the client's feelings and reinforce reality rather than argue or present evidence that the delusion is false or irrational. Additional Information Psychosocial Integrity NCSBN Client Need
The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply. 1. Allow the client to remain on current laxatives 2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 1-2 hours after each meal in central area
Answer: 2,3,5 Bulimia nervosa is an eating disorder common among adolescent girls and characterized by cycles of uncontrollable overeating (binging) followed by compensating behaviors to avoid weight gain (purging). Weight-maintenance behaviors include self-induced vomiting, fasting, laxative abuse, and excessive exercise. Clients may be of normal weight, which contributes to the hidden nature of this disorder. Clients with bulimia often experience extreme guilt associated with their increasing lack of control and attempt to hide evidence of their actions (eg, hidden food wrappers from binging, discarded food from unfinished meals). Clients should be monitored around meal times, and particularly for 1-2 hours after eating to observe for purging. Purging behaviors, particularly vomiting, may result in electrolyte imbalances, such as hypokalemia, that can cause cardiac arrhythmias. (Option 1) Clients with bulimia nervosa often use laxatives inappropriately to rid their bodies of undigested food in an effort to control their weight. Such measures should not continue in the treatment setting. (Option 4) A food diary helps the client and caregivers track the type and amount of food that the client has eaten. It is also an excellent means of helping the client understand the health implications of the disorder. Educational objective: Clients with bulimia nervosa should be monitored for signs of hidden binging or purging activity, particularly for 1-2 hours after meals. Excessive vomiting may result in electrolyte imbalances, including hypokalemia. Additional Information Psychosocial Integrity NCSBN Client Need
The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply. 1. Bradypnea 2. Diaphoresis 3. Hallucinations 4. Lethargy 5. Tachycardia
Answer: 2,3,5 One of every 6 clients undergoing an emergency surgical procedure will show some signs of alcohol withdrawal during the hospital stay. Screening for heavy use of drugs and alcohol should occur at several points during hospitalization to avoid complications of withdrawal. Delirium tremens and other withdrawal symptoms can be prevented with benzodiazepine administration during hospitalization. The stages of alcohol withdrawal do not always occur as a progressive sequence. (Option 1) Decreased respiratory rate is not a sign of alcohol withdrawal. It is more commonly seen in alcohol or opiate overdose. (Option 4) Clients experiencing alcohol withdrawal symptoms will be agitated and have tremors and hyperreflexia. Educational objective: Alcohol dependency is frequently missed during the admission process. Clients should always be screened for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable. Signs and symptoms of delirium tremens include
The nurse is caring for a client with a history of heroin abuse. Which clinical finding may indicate withdrawal? 1. Constipation 2. Constricted pupils 3. Drowsiness 4. Tachycardia
Answer: 4 Opioid withdrawal Time course: - 4-8 hours after opioid cessation - Immediately after opioid antagonist (life-threatening) Clinical Presentation: - Gastrointestinal: nausea, vomiting, cramping. diarrhea, increased bowel sounds - Cardiac: increased pulse, increased blood pressure, diaphoresis - Psychologic: insomnia, yawning, dysphoric mood - other: myalgia, arthralgia, mydriasis, lacrimation, rhinorrhea, piloerection Diagnosis: - History & examination alone (clinical diagnosis) Management - Opiod Agonist: methadone or buprenorphine - nonoploid: clonidine or adjunctive medications (antiemetics, antidiarrheals, benzodiazepines) Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone [Narcan]) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes (Option 4). Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions. (Options 1, 2, and 3) Opioid use typically causes constipation, constricted pupils, and drowsiness due to its central nervous system depressant effects. Educational objective: Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped or dosage is reduced. Symptoms of opioid withdrawal (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity.
The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include? 1. Disulfram is not a cure for alcoholism 2. Importance of continuing to see a therapist 3. List of everyday items containing hidden alcohol 4. Medical alert bracelet should identify disulfram therapy
Answer: 3 Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist (Options 1 and 2). Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: -Avoid hidden alcohol in: - liquid cold and cough medications - aftershave lotions, colognes, and mouthwashes - foods such as sauces, vinegars, and flavor extracts - Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur - Wear a bracelet alerting others of being on disulfiram therapy (Option 4) Educational objective: Disulfiram is a medication that promotes abstinence from alcohol by causing uncomfortable, potentially fatal reactions when alcohol is consumed. Clients must avoid sources of hidden alcohol (eg, liquid cough medicine, aftershave, mouthwash). Effects of the drug can last 2 weeks after the last dose.
The nurse is speaking with the spouse of a client following a family discussion with the health care provider about the client's terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond? 1. I find it helpful to investigate the options. I will get you a pamphlet about hospice services 2. It's hard to say what the best decision is, but I know hospice provides wonderful care 3. These decisions are challenging. Tell me your spouse's beliefs about end-of-life. 4. You seem overwhelmed. I'll contact a chaplain to come and talk with you about the options
Answer: 3 End-of-life decisions (eg, hospice, code status) often overwhelm clients and medical decision-makers due to the magnitude of the choices and feelings of guilt that may accompany decisions. Clients and their families may lean on hospital staff to guide these decisions. These moral and ethical dilemmas require the nurse to have strong therapeutic communication skills. When discussing decisions related to client care, the nurse should facilitate exploration of the client's emotions, values, and beliefs, rather than offer personal opinions. Nurses can promote self-exploration by using open-ended questions and guiding phrases (Option 3). (Option 1) Providing information is an appropriate response when that is what the client is seeking. However, there is no indication that the spouse seeking advice requires additional information, and this response does not promote further communication. (Option 2) The nurse's opinion and personal biases can influence clients/family members and may even push them toward decisions incongruent with their values and beliefs. Giving advice is not therapeutic and does not promote open communication. (Option 4) It is within the nurse's scope to discuss moral and ethical decisions with clients. Deferring these conversations to another professional (eg, chaplain) instead of talking with the individual inhibits the therapeutic relationship and does not support client self-exploration. Educational objective: When discussing ethical decisions related to client care, it is important for the nurse to use open-ended questions and guiding phrases to facilitate exploration of clients'/family members' emotions, values, and beliefs regarding the topic. Nurses should avoid giving advice and influencing individuals' decisions.
An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful? 1. "I am busy right now but can stay for a few minutes." 2. " I can call the clergy to come sit with you." 3. " I can stay and sit with you if would like." 4. " I don't think I should interrupt your family time."
Answer: 3 During the end-of-life process the client's family members may be frightened, sad, confused, or concerned, and may ask staff questions about belief systems or the death process. Sometimes clients or family members simply want the nurse to sit with them and provide reassurance that their loved ones are worthy of time and attention. The most therapeutic response by the nurse is to sit with the client and/or family for at least a few minutes. (Option 1) Telling family members that a nurse is busy is not a helpful response. They may feel guilty about asking for the nurse's time and attention. If needed, the nurse can ask coworkers to help with other assigned clients. (Option 2) Although calling clergy members may be appropriate, it may take several hours for them to arrive. This is not the most helpful response. (Option 4) Family members who ask the nurse to stay for a few minutes may have questions or need emotional support. In such cases, it is not helpful for the nurse to decline. Educational objective: During the end-of-life process, the client and family members typically go through several emotional stages, each requiring therapeutic communication techniques by the nurse. The nurse can help the client and family by providing a few minutes of time and attention. The nurse should validate the family's needs by providing emotional support.
A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD). She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar." What is the best response by the nurse? 1. It may take time to overcome those thoughts and feelings 2. Those kinds of thoughts are self-destructive. You should stop thinking about it. 3. You could not have anticipated the rape. You did not deserve or ask for it 4. You have to stop blaming yourself so you can move on with your life.
Answer: 3 One of the common features of PTSD is a persistent distorted perception about the cause of the traumatic event that leads the affected individuals to blame themselves or others. Clients may be in a persistent, negative emotional state of guilt and/or shame and also believe that they are responsible for what happened. This is particularly true in cases of rape. A pervasive culture of "blaming the rape victim" also contributes to clients' perception that the rape was somehow their own fault. Providing a realistic perspective of the rape may help clients develop a more objective view of their perceived role in the traumatic event and may reduce feelings of self-blame and guilt. The nurse needs to reinforce repeatedly that rape is never the victim's fault (Option 3). (Option 1) This is a nontherapeutic response as it reinforces the client's feelings of self-blame and guilt. The best therapeutic response should reinforce that the client is not to blame for the rape. (Option 2) This is a nontherapeutic response; it does not assist in changing the client's perception of the traumatic event and implies that the client should not cope with the experience at all. (Option 4) This is a nontherapeutic response. Clients cannot simply make negative feelings disappear; these need to be resolved through therapy. Educational objective: Clients who suffer from PTSD often experience feelings of guilt and shame; they believe that they are responsible for what happened and that, somehow, they could have prevented the traumatic event. Using therapeutic communication, the nurse needs to convey that what happened was not their fault.
The nurse is admitting a client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate to include in the care of this client? Select all that apply. 1. allow the client to continue to exercise per usual routine 2. assist the client in reflecting on triggers of discorded eating 3. maintain strict record in reflecting on triggers of disordered eating 4. remain with the client for the duration of each meal 5. weigh the client each morning prior to any oral intake
Answer: 3, 4, 5 Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically in a crisis state, and the priority is restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes: - Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight (Option 2) - Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain (Option 3) - Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors (Option 4) - Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk]) - Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing to assess efficacy of nutritional support (Option 5) - Limiting physical activity initially and gradually increasing as oral intake improves - Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight (Option 1) Clients admitted with anorexia nervosa should not continue to exercise, because this would cause further energy deficit and worsen malnutrition and end-organ damage (eg, renal failure). Educational objective: Clients admitted with anorexia nervosa must increase caloric intake and stop exercising to promote weight gain. The nurse should record consumed calories, weigh the client daily, remain with the client during and for 1 hour following meals, and encourage discussion about dysfunctional eating triggers.
A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium? 1. 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3. 60-year-old client with type 2 diabetes, 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease , chronic respiratory failure, and urpsepsis
Answer: 4 Major predisposing factors for the development of delirium in hospitalized clients include: Advanced age Underlying neurodegenerative disease (stroke, dementia) Polypharmacy Coexisting medical conditions (eg, infection) Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) Metabolic and electrolyte disturbances Impaired mobility - early ambulation prevents delirium Surgery (postoperative setting) Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. (Option 1) Although gastroenteritis with possible dehydration and electrolyte imbalances predisposes to delirium, this client is not at greatest risk. (Option 2) Although surgery, especially that requiring cardiac bypass, predisposes to delirium, this client is not at greatest risk. Early ambulation and adequate pain control prevent the development of delirium in the postoperative setting. (Option 3) Although coexisting medical conditions, such as diabetes mellitus and impaired mobility, predispose to delirium, this client is not at greatest risk. Educational objective:Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control.
A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action? 1. Encourage the client to perform deep breathing 2. Explore possible reasons for he episode 3. Place the client in a private room and tell the client to relax 4. Remain in the room with the client
Answer: 4 This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support. Additional nursing actions while the client is experiencing panic symptoms include: - Maintaining a calm, matter-of-fact approach - Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures - Placing the client in a room with as few stimuli as possible - Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription) - Having the client take slow, deep breaths if hyperventilation is a problem (Option 1) Deep breathing exercises can relieve hyperventilation, but the priority is to remain with the client to ensure safety. (Option 2) Discussing the reasons for the panic attack is not appropriate while the client is still symptomatic. Once the client has calmed down, the nurse can discuss reasons for the attacks, evaluate stressors in the client's life, and assist the client in developing prevention strategies. (Option 3) A private room is appropriate; however, just telling a client to relax is not helpful. Educational objective: The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment, ensure the client's safety, and offer support.
The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take? 1. ask the client to make a verbal contract to not harm self 2. document that the client is not currently suicidal 3. place the client in an inside hallway with one-on-one observation 4. return the client to the waiting room with the spouse
Answer: 4 Any client who cannot definitively say that currently he/she is not suicidal should be considered a "yes" and appropriate protective measures should be instituted to prevent suicidal actions. The client is under the hospital's care and the department must assume responsibility for the client's safety. Placing the client in an inside hallway can prevent the client from running outside. The client needs constant supervision by a hospital employee until a secure room is available. The client should never be left alone without hospital supervision. (Option 1) A verbal contract is a viable option but might not be accomplished appropriately in the triage area. Also, its efficacy is questionable. Emergency department triage should be accomplished in 3-5 minutes. In addition, the triage nurse may not have the skills to adequately perform this intervention. Safety should always be the first priority, and precautions should be taken until the client is determined to not be suicidal. (Option 2) Any ambivalence, especially given the client's previous actions and statements, should be considered a "yes." (Option 4) It is unfair to expect the spouse to perform the same level of care as a health care provider; the spouse brought the client to the hospital for additional help. It would be appropriate to have the spouse present with the client in a secure setting. The spouse would also be instructed to keep the client in sight at all times. Having the client and spouse return to the waiting room would provide the opportunity for the client to bolt from the hospital. Educational objective: Any client who expresses ambivalence about being suicidal should be treated as a "yes." The client must be in a safe environment with hospital supervision and should not be left alone.
The nurse assesses a pediatric client and finds bruises in various stages of healing on the back and legs. When questioned about the bruises the child begins to cry and states, "Somebody did things to me." Which of the following communications by the nurse is appropriate? Select all that apply. 1. How long have your parents been doing this to you? 2. Tell me about what happened. I promise not to tell anyone." 3. This is terrible. Whoever did this to you will be sorry. 4. What happened is not your fault. You are not to blame. 5. You did the right thing by telling me. You are not in trouble.
Answer: 4&5 When speaking with a child about abuse, the nurse should be direct and honest. The nurse should allow the child to disclose the abuse at a comfortable pace, rather than probe for additional information. The nurse should use open-ended questions and avoid leading questions and statements. Guidelines for the interview: - Speak with the child in private - Be honest about reporting requirements - Use language appropriate to the child's age - Avoid making assumptions or communicating anger, shock, or disapproval - Reassure the child about not being at fault or in trouble (Options 4 and 5) (Option 1) The nurse should not make assumptions about who abused the child. This could lead to bias or false accusations and/or cause the child to fear revealing the identity of the abuser. (Option 2) "Tell me about what happened" is a correct, open-ended question; however, the nurse is required to report abuse and should communicate this requirement to the child. (Option 3) The nurse should avoid making derogatory statements about the abuser, as this can cause the child feelings of embarrassment or fear and end the conversation. Educational objective: When interviewing a child about abuse, the nurse should affirm that the child is not at fault or in trouble and avoid making assumptions or communicating anger, shock, or disapproval. The nurse should be direct and honest about the requirement to report abuse.
The nurse is conducting a follow-up interview with a client who is being treated for depression and suicidal ideation. Which factor best indicates the client is not currently at risk for suicide? 1. Client claims to have more energy and vigor since starting therapy 2. Client has clear future plans involving personal goals and family milestone 3. Client has signed a contract promising not to commit suicide 4. Client reports losing amitriptyline and requests a refill
Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing intent. During the client interview, the nurse should assess: - Access to psychiatric medications - Availability of help during a crisis (eg, counselor, family) - Future goals and plans - Home and work environment risks - Overall affect and level of energy - Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to commit suicide (Option 2). (Option 1) Clients often feel more energetic after beginning treatment, yet thoughts of suicide may not have fully resolved and the client may now have the energy to follow through with suicide plans. (Option 3) "No-harm/no-suicide" contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. This practice is controversial as there is no evidence that contracts reduce suicide rates. These agreements do not guarantee safety and have no legal credibility. (Option 4) Amitriptyline is a tricyclic antidepressant, an overdose of which is extremely dangerous and likely fatal. Although the nurse may interpret the client's report of having lost the prescription as an attempt to be compliant, the nurse must also be aware that the client may be "stockpiling" medication for a suicide attempt. Educational objective: Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric medications, overall affect, and energy level. Clients who articulate long-term personal goals are less likely to commit suicide.
A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the best response by the nurse? 1. At the moment, I would worry more about how your sibling is doing 2. the odds are about 50-50 that will come down with the disease as well 3. Would you like to talk to a health care provider about this 4. You are at risk for the disease. However, there are other factors that contribute o the development of schizophrenia
The best response should acknowledge the reality of the sibling's concern, provide information, and open the door to further discussion about the development of the disease. Research studies indicate that identical twins have about a 50% chance of developing schizophrenia if one twin develops the disease. This points to a genetic component, but schizophrenia is not entirely a genetic disease. The exact cause is unknown; it most likely results from the interaction and combination of a number of different risk factors. Theories about the cause of schizophrenia include the following: - Biochemical theories - abnormalities affecting the neurotransmitters dopamine, serotonin, norepinephrine, and glutamate - Structural brain abnormalities - reduced size of certain brain areas - Developmental factors - prenatal factors such as faulty neuronal connections - Miscellaneous factors - birth trauma, epilepsy, maternal influenza during pregnancy (Option 1) This response ignores the sibling's concerns and is judgmental. (Option 2) This statement presents the facts in a blunt, non-therapeutic manner; it does not facilitate further discussion about the factors contributing to schizophrenia and/or the sibling's feelings. (Option 3) This dismisses the sibling's concerns and is basically a "non-action" on the part of the nurse Educational objective: Information regarding the potential for development of a serious illness, such as schizophrenia, needs to be provided to clients in a realistic manner that allows for discussion and exploration of the client's feelings. The exact cause of schizophrenia is unknown and is probably a combination of genetic, biochemical, structural, and developmental factors.
Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. 1. Amenorrhea 2. Fluid and Electrolyte imbalances 3. Heat intolerance 4. 5. 6.
answer: 1, 2, 4, & 6 Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: 1. Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. 2. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis 3. Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) 4. Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance 5. Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. (Option 3) Anorexia nervosa manifests as cold intolerance. (Option 5) Anorexia nervosa manifests as lengthy and vigorous exercise. Educational objective: The clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea, bradycardia, cold intolerance, dry skin, and lanugo. Life-threatening complications, such as cardiac arrhythmias associated with hypokalemia, may develop.