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Alcohol withdrawal generally starts within 8 hours after the last drink and peaks at 24-72 hours. Alcohol can cause hypoglycemia, but intoxication can make it difficult to differentiate between the effects of alcohol and hypoglycemia. Clients with acute alcohol intoxication, especially those who have diabetes mellitus, should have their blood glucose levels monitored. Acute alcohol intoxication can cause confusion, coordination impairment, drowsiness, slurred speech, mood swings, and uninhibited actions. Alcohol can also cause hypoglycemia, especially in clients with diabetes mellitus.

Although antipsychotic medication is the first-line treatment for diminishing or eliminating psychotic symptoms, such as hallucinations, clients need other strategies for coping with distressing symptoms. Increasing external auditory stimulation often helps distract the client from the internal voices and focus on reality. ex: listening to music and singing along with the song

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) -pt refuses food and water for 4 days -client repeats "I must kill them before they get me"

Functional disorders are currently undiagnosable medical issues and should not be confused with psychosomatic illness, attention-seeking behavior, or malingering. It is a general diagnosis for genuine medical issue that medical science does not yet fully understand. "you have something we just dont have a name for it yet"

(Option 1) Clients with dependent personality disorder will often express appreciation or make flattering comments to the nurse/therapist to gain approval.

Other examples of delusions are below: Grandeur - "I need to get to Washington for my meeting with the president." Control - "Don't drink the tap water. That's how the government controls us." Nihilistic - "It doesn't matter if I take my medicine. I'm already dead." Somatic - "The doctor said I'm fine, but I really have lung cancer."

An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate? 1. "Don't you know it's not morning yet?" [2%] 2. "It's time to get back to bed now." [61%] 3. "You might fall if you wander in the dark." [18%] 4. "You should not leave your room without assistance." [16%].....This statement has a paternalistic tone and seems to penalize the client. This type of statement may cause the client to get angry, leading to escalating negative behaviors. correct answer: 2 Sundowning refers to the increased confusion experienced by an individual with dementia; it occurs at night, when lighting is inadequate, or when the client is excessively fatigued. Wandering is a common associated behavior. A client with mild-to-moderate dementia may need frequent reality reorientation to promote appropriate behaviors. However, with advanced dementia, reality orientation may not be effective and might cause the client to feel anxious, leading to inappropriate behaviors and aggression. In this situation, validation therapy is more appropriate and involves recognizing and exploring the client's feelings and concerns but not reinforcing or arguing with any incorrect perceptions.

The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, "It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore." Which response by the nurse is best? 1. "Perhaps finding a caregiver to care for your spouse at night might be helpful." [3%] 2. "Tell me about the care you provide in a typical day and its challenges." [58%] 3. "Try not to worry. It's normal to feel overwhelmed when you are stressed." [0%] 4. "You seem worried that you won't be able to provide the care that your spouse needs." [37%] correct: 2

A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for most of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the best nursing action? 1. Engage other staff members to remove the client from the bathroom [0%] 2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break [76%] 3. Tell the client that the bathroom is very clean and that this behavior is unreasonable [7%] 4. Tell the roommate to use the shower in another room [15%] Correct 2 Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions (recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will experience increased anxiety. A client with compulsive behavior often does not realize the amount of time or how many times the same activity has been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-solving skills. (Option 1) Engaging other staff members to remove the client from the bathroom is confrontational and will increase the client's and roommate's anxiety; this approach is not necessary or therapeutic. (Option 3) Pointing out that the bathroom is clean does not change the client's obsessive thoughts. Saying that the client's behavior is unreasonable conveys a message of disapproval and would increase the client's anxiety. (Option 4) Telling the roommate to use a different bathroom allows the client to continue the ritualistic behavior, is non-therapeutic, reinforces the behavior, and avoids the issue. Educational objective: Clients with OCD engage in rituals and activities that help reduce the anxiety associated with unacceptable thoughts, images, and impulses. Therapeutic approaches to a client with OCD include pointing out the amount of time the client has spent performing an activity and redirecting the client to another activity.

The nurse cares for a client who has a do-not-resuscitate prescription, and notes extensive skin mottling and vital signs consistent with impending death. The client's spouse states, "I hope my spouse can hang on a little longer; our anniversary is in 2 days." What response by the nurse is appropriate? 4. "Your spouse's body is shutting down and the time is near; I will stay here with you." [38%] When assisting a client's family through the dying process, the nurse should provide factual, open, and honest communication; help the family anticipate what is happening and when death is imminent; and use the therapeutic technique of offering self.

Memantine is a medication used in the treatment of moderate to severe Alzheimer disease (AD). It slows the progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive functioning, and ability to perform activities of daily living. Memantine does not cause rapid improvement of cognitive functioning; it usually takes weeks or months before such improvement is noticeable

Clients with schizoid personality disorder exhibit social detachment and an inability to express emotion. They do not enjoy close relationships and prefer to be aloof and isolated.

Communication with a client experiencing a hallucination should first focus on the nature of the hallucination so that the nurse can assess for suicidal or homicidal themes. so if a schizophrenic pt looks away suddenly and makes a face ask what they are seeing.... it could be something bad

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.

The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply. 1. Client has had school disciplinary issues due to absenteeism and angry outbursts 2. Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying 3. Client is often found sleeping during class or activities 4. Client quit sports despite receiving previous athletic awards and trophies 5. Client voices concern about appearance related to facial acne Correct answer 1,2,3,4 Adolescent clients are at increased risk for developing depressive and anxiety-related mood disorders as they begin to identify their role in adult life and develop new personal relationships. However, they frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. Signs of depression in adolescent clients include: Hypersomnolence or insomnia; napping during daily activities (Option 3) Low self-esteem; withdrawal from previously enjoyable activities (Option 4) Outbursts of angry, aggressive, or delinquent behavior (eg, vandalism, absenteeism); inappropriate sexual behavior (Option 1) Weight gain or loss; increased food intake or lack of interest in eating (Option 2) Depression is also a significant cause of suicide in adolescents. (Option 5) Adolescent clients begin to become more aware of body image and may express concern regarding their appearance. It is normal for clients in this age group to experience insecurity about their appearance (eg, acne, body hair). These insecurities do not correlate with the onset of a depressive disorder. Educational objective: Adolescent clients with depression frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. In addition, changes in sleep patterns; low-self esteem; withdrawal from previously enjoyable activities; outbursts of aggressive or delinquent behavior; and precipitous weight changes may indicate the onset of a depressive disorder.

Reduced appetite and low energy level are common clinical findings in major depressive disorder. The lethargy accompanying the depressed mood makes it difficult for a client with this diagnosis to even get up and out of bed. Personal hygiene and grooming are neglected, and there is no desire to interact with others. The client needs direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self esteem.

e 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 to blow up a balloon 3. Give the child a "time out" in a quiet place 4. Reinforce the consequences of disruptive behaviors....this isn't the answer bc best action is to help the child calm down and relax first. the answer is 2 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. 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.

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.

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

Typical characteristics of child abuse perpetrators include: Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child Confusion between punishment and discipline; having a stern, authoritative approach to discipline Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation (Option 1) Low self-esteem—a sense of incompetence or unworthiness as a parent (Option 4) A history of substance abuse; use of alcohol or drugs at the time the abuse occurs (Option 2) Punitive treatment and/or abuse as a child Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age (Option 5) Resentment or rejection of the child Low tolerance for frustration and poor impulse control Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury (Option 3) Child abusers are not easily identified by appearance; they often appear calm and well in control but may have violent outbursts, typically in private.

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

ADHD interventions 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

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks? Depressed mood or loss of interest or pleasure Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client. For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2 weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure.

school phobia -Having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery. If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day. A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships. - Having the parent/caregiver stay in the classroom with the child is not a permanent solution to relieving the child's anxiety and is not recommended.

Nonpharmacological strategies for improving sleep hygiene include: Avoiding naps throughout the day Engaging in physical activity or exercise, preferably at least 5 hours before bedtime Receiving at least 20 minutes of natural sunlight each day, ideally in the morning, to improve sleep patterns Avoiding caffeinated beverages after noon Avoiding alcohol and/or smoking at bedtime Participating in a relaxing activity before bedtime (eg, warm bath, reading, listening to soft music) Decreasing environmental stimuli; making sure the bedroom is dark, cool, and quiet Avoiding heavy meals or large amounts of fluids at bedtime Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which promotes comfort and relaxation to aid sleepiness

*A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia, and confusion. The client's breath smells of alcohol. Which prescription from the health care provider should the nurse implement first?* Thiamine IV bc... lients with alcoholism can have hypoglycemia. They can also have thiamine (vitamin B1) deficiency related to poor nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can result in Wernicke encephalopathy (WE). Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis). In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual. Because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose (Options 2 and 4) IV thiamine is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. Clients with alcoholism often have thiamine deficiency.

-dont pass the buck or make referrals unless you really have to -any option that has the client expressing their feelings or just talking more "open ended" questions is usually the correct answer -Do no make referrals or give phamplets when the client is stressed -

when dealing c mental health questions..

A client with schizophrenia is hospitalized. After 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing. When first hospitalized, the client refused to leave the room. Now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. What is the most appropriate activity for the client? 1. A board game with a staff member [64%] CORRECT 2. Participation in a group songfest [8%] 3. Planning a unit picnic [7%] 4. Playing Bingo with other clients [19%] Clients with schizophrenia have difficulty initiating and maintaining social interactions with other people. The nurse can facilitate interpersonal functioning by providing one-on-one interaction in which the client can practice basic social skills in a non-threatening way. Once the client feels more comfortable, the nurse can encourage participation in activities that require some interaction with others.

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? CHECK VITAL SIGNS... we don't know why he got lost, we dont know what he may have, heck it could be a severe brain injury so we need to asses the patient. 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.

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 is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the best action by the nurse? 1. Have the client keep a journal and write about feelings [28%] 2. Initiate one-on-one supervision of the client during feedings [38%] 3. Remind the client that gaining weight means being able to go home [16%] 4. Say that the client is not fat and ugly [15%] Correct 38% Answered correctly 152 Seconds Time Spent 06/30/2018 Last Updated Explanation Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for medical complications from anorexia nervosa, including death. Criteria for nutrition support include: Severe weight loss that is life threatening Client's unwillingness to adhere to a treatment plan of oral feedings The priority nursing actions for this high-risk client include interventions to meet physiological and safety needs. Providing one-on-one supervision during the tube feeding will ensure that the client is actually receiving the feeding and prevent the client from stopping the feeding and/or pulling out the nasogastric tube. During the one-on-one contact with the client, the nurse can promote a therapeutic and trusting relationship with the client by: Being honest and accepting of the client Presenting the reality of the condition Acknowledging the client's feelings of loss of control and anger Encouraging the client to express feelings and fears (Option 1) This is an appropriate intervention for a client with anorexia nervosa. Feelings related to lack of control are an underlying problem for these clients, who use food as a way to deal with them. Keeping a diary or journal of feelings will help the client recognize and express them more clearly. However, this is not the priority nursing action. (Option 3) This may be a true statement; clients with anorexia nervosa are usually discharged to out-patient follow-up and treatment or to a residential treatment facility once an acceptable weight gain has been achieved and maintained. However, this is not the priority nursing action. (Option 4) Clients with anorexia nervosa have a distorted body image and a morbid fear of being overweight; they perceive themselves as "fat and ugly" even when they are emaciated. Saying that the client is not "fat and ugly" will not change this perception. Educational objective: The priority nursing care for a client with anorexia nervosa is nutritional rehabilitation and prevention of medical complications, including death. Clients who are severely ill and/or resistant to oral refeeding may require nutrition support with intense monitoring to achieve adequate caloric intake and weight gain.

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. Treatment for a client requiring hospitalization for anorexia nervosa should focus on the short-term outcomes of increasing caloric intake, promoting gradual weight gain, and addressing medical conditions caused by starvation.

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? 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.

Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one partner against another in an intimate relationship, to maintain power and control. Nurses must be aware of the risk factors and signs of IPV to recognize victims of abuse and to intervene (eg, separating the victim from the abuser during the health history interview, providing information about community resources). Features of IPV include: The abusive partner exhibits intense jealousy and possessiveness (Option 3). The victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody concerns, religious beliefs) (Option 4). The abuse begins or intensifies during pregnancy (Option 5). (Options 1 and 2) IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships.

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan? 1. Assign different staff members to care for the client each day [17%] Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to rotate staff members assigned to care for the client. Individuals with borderline personality disorder (BPD) live in fear of rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person. An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving.

delirium. The signs are acute mental status changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and pain. Delirium has an abrupt onset and is a symptom of other problems. Up to 60% of hospitalized elderly clients have delirium prior to or during hospitalization, but it is often missed by nursing.

A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: Immobility—the client remains in a fixed stupor or position for long periods Refuses to move about or engage in activities of daily living May have brief spurts of excitement or hyperactivity Remaining mute Bizarre postures—the client holds the body rigidly in one position Extreme negativism—the client resists instructions or attempts to be moved Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person Staring Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care.

Bulimia nervosa is characterized by episodes of uncontrollable binge eating (consuming very large amounts of food) followed by inappropriate behaviors to prevent weight gain. Self-induced vomiting within 1-2 hours of binge eating is the more typical behavior; use of enemas and laxatives, and frequent, intense exercise are also characteristic behaviors of the client with bulimia nervosa. Signs that a parent or friend of someone with this disorder might notice include the following: Trips to the bathroom after meals Disappearance of large amounts of food Finding hidden wrappers and empty containers of food, especially foods that are sweet and easily consumed Smells of vomit; finding packages of laxatives or enemas Getting up in the middle of the night followed by a trip to the bathroom some time later Engaging in intense physical exercise despite fatigue or pain Swelling of the cheeks due to parotid gland damage and enlargement; staining of the teeth Periods of starvation Preoccupation with weight, food, and dieting A pt c this will inc exercise not stop it

A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take? 1. Ask where the client is going [38%] 2. Immediately follow the client out the door [10%] 3. In a loud voice, direct the client to come back to the room [2%] 4. Remain silent and allow the client to leave [48%] correct answer is : 4 Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a poor quality of life. Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the following: Making brief, frequent contacts Accepting the client unconditionally by minimizing expectations and demands Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients Being with or close by the client during group activities Offering positive reinforcement when the client interacts with others (Option 1) Asking where this client is going is nontherapeutic as it requires an explanation of the client's actions. (Option 2) Following this client out the door could increase the client's anxiety. (Option 3) Directing this client to come back to the room is placing a demand that may be unrealistic and does not help develop a sense of trust. Educational objective: Social isolation and impaired social interaction are common negative symptoms of schizophrenia. The client will seek to be alone to relieve anxiety associated with being around others. The nurse needs to be accepting of the client's behavior and continue attempts at brief contact until the client is comfortable.

The clinical characteristics of narcissistic personality disorder can best be explained as an attempt to maintain a fragile self-esteem that was damaged during childhood due to an environment that was highly critical, demanding, and fostered a sense of inferiority.

A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. The client has a history of physical violence. Which intervention should the nurse implement at this time to prevent the client from becoming violent? 1. Administer prescribed PRN lorazepam and apply soft wrist restraints [8%] 2. Explain all activities of care clearly and calmly while facing the client [66%] 3. Place the client in the room that is closest to the nurses' station [12%] 4. Request security personnel to be present to protect clients and staff [12%] Incorrect Correct answer 2 Violence in the health care setting poses a safety risk to clients, staff, and visitors. It also decreases the quality of care that a violent client receives due to avoidant and fearful behaviors by staff. Risk factors for violence include altered level of consciousness, substance abuse, emotional stress, and behavioral/psychiatric disorders. Nursing interventions that help prevent violence include using clear, thorough communication (Option 2); encouraging active participation in care; promoting a low-stimulation environment; and providing comfort through pharmacological and nonpharmacological methods. The nurse should demonstrate undivided attention to the client (eg, facing the client, unhurried body language, calm tone). (Option 1) Chemical (eg, lorazepam) and physical restraints should be used only as last resorts to keep clients and others safe. It is not appropriate to use restraints to prevent escalation to violence. (Option 3) Placing the client near the nurses' station may increase anxiety due to the noise and activity in that area. The client should be closely monitored, but this is not an effective intervention for preventing violence. (Option 4) The presence of security personnel does not prevent violence and may cause increased client anxiety. The nurse should consider other interventions (eg, effective communication) to prevent violence. Educational objective: Violence is a safety concern for all in the health care setting. Nurses must identify those at risk for violent behavior and use clear, thorough communication to prevent violence. The nurse should provide undivided attention to the client while explaining all activities of care in a calm tone.

Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. The individual may not have the energy or ability to perform activities of daily living or to interact with others. Psychomotor retardation may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior). Specific clinical findings of psychomotor retardation include the following: Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait Lack of facial expression Downcast gaze Speech impairment - reduced voice volume, slurring of speech, delayed verbal responses, short responses Social interaction - reduced or non-interaction Clients with major depressive disorder may also show symptoms of psychomotor agitation, characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye movement.

Activities for children with intellectual disabilities should be based on the child's developmental age with consideration given to size, coordination, physical fitness, maturity, likes and dislikes, and health status. A child with moderate intellectual disability: Has academic skills at about the 2nd grade level and may be able to work in a sheltered workshop Performs self-care activities with some supervision Participates in simple activities May have limited speech capabilities Appropriate play activities for this child include simple puzzles, coloring books and crayons, modeling clay, watching cartoons or favorite movies, sticker books, playing with a large ball (eg, inflatable beach ball), simple card and board games, and being read to aloud

Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients with anorexia exhibit preoccupation with body image and obsessive behaviors to lose weight (ie, excessive exercising/dieting). Clients commonly have protein-energy malnutrition and may be extremely underweight. Acute care focuses on restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes: Determining minimum caloric intake for healthy weight gain and documentation of consumed calories and protein (Option 3) Establishing a weekly weight-gain goal - an appropriate goal for most clients is 2-3 lb/wk (0.91-1.36 kg/wk) Limiting physical activity initially and gradually increasing as oral intake improves Allowing client to make food choices, when possible, to give a sense of control Providing reflection with the client about behaviors, triggers, or situations that cause dysfunctional eating (Option 2) Weighing the client at the same time each day, after voiding, and wearing the same clothing to assess efficacy of nutritional support (Option 5)

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction? 1. Ensure that the client is never left alone [34%] 2. Notify neighbors of the client's tendency to wander [1%] 3. Place a chain lock on the door above or below the client's eye level [33%] 4. Place a safe return bracelet on the client's non-dominant hand [30%] CORRECT: 3 The most effective strategy to prevent wandering is to make modifications to secure the environment. These include: Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads (Option 3). Adding a motion sensor or alarm that goes off when someone tries to exit Placing a large stop sign on door exits Disguising a door with a curtain or wall hanging Using childproof doorknob covers Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception. (Option 1) Clients with AD should not be left alone; however, it is impossible for any caregiver to watch another person every minute of the day. Clients with AD can walk out of their homes while family members are sleeping. (Option 2) Notifying neighbors can be helpful if the client leaves the residence but will not prevent wandering. (Option 4) Safe return or identification bracelets are important, but they will not prevent wandering. A bracelet should be placed on the dominant hand to minimize the chance of removal.

The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: Poor self-esteem Increased risk for depression and anxiety Increased risk for substance abuse Academic or work failure Trouble interacting with peers and adults

An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action? 3. Providing one-on-one supervision [65%] This client is experiencing impairment in cognitive and psychomotor functioning and most likely has delirium brought on by the urinary tract infection. This is not an uncommon occurrence in elderly clients. The client's most immediate needs are safety and prevention of physical injury. Initially, the client should be placed in a room near the nurses' station with one-on-one supervision and frequent reorientation to time, place, and situation. As the condition improves, the client will continue to require frequent observation. A dark room could worsen the client's confusion, agitation, and disorientation. Lighting helps maintain orientation to the environment; the client's room should be well lit during the day, and dim nightlights should be used at night.

The nurse is caring for a dying child on a palliative unit. Which statement by the nurse is most important to make to the parents immediately following the death of their child? 1. "Finding support with other local grieving parents can be helpful." [2%] 2. "Self care is important at this time. Take a break while the staff completes care." [0%] 3. "Some parents like to cuddle and speak to the child. Take the time you need." [79%] 4. "This must be a very difficult time. How have you dealt with loss in the past?" [17%] correct: 3 Postmortem care of a child is a highly stressful and emotional time for family and staff members. After death, the psychosocial care of the family and the bond between parent and child should be facilitated through specific interventions intended to assist parents through the grieving process. Parents should be allowed as much time as they need with the child's body and should not be rushed while they say goodbye. The nurse should be present to provide emotional support and identify if parents wish to help participate in some or all care activities, such as bathing and dressing the child. Parents should be allowed time to cuddle with and speak, read, or sing to the child, as well as perform special activities associated with cultural beliefs (Option 3). (Options 1 and 4) Providing community resources for grief support groups and assessing parents' coping mechanisms are important interventions; however, this is not a priority immediately following the death of a child. (Option 2) Self care is important during the grieving process; however, parents should first be provided the opportunity to be involved in the postmortem care of their child. Educational objective: Nurses should provide emotional support and facilitate the parent-child bond in the immediate moments following the death of a child. Participation in postmortem care promotes the psychosocial wellness of the family.

An adolescent client is brought to the emergency department by the parents after being found making superficial cuts along the side of an arm with a razor blade. There are several minor cuts in various stages of healing on the client's forearms. Which statements are appropriate for the nurse to make to the client's parents? Select all that apply. 1. "Everything is going to be all right." 2. "Tell me about when you started noticing this behavior." 3. "We have the bleeding under control." 4. "Why didn't you bring your child in sooner?" 5. "You must be very upset after seeing this." CORRECT: 2,3,5 Broad openings and relevant questions can help uncover important information that will assist with decision making (Option 2). Therapeutic communication gives relevant information to the parents about the physical condition of the client to help alleviate their anxiety (Option 3). Empathetic statements establish trust and encourage expression of feelings (Option 5). Self-injury (eg, cutting) in adolescence is commonly a coping mechanism used when a client is emotionally overwhelmed. Although not necessarily a suicide attempt, it is a clear indication that this client is unable to process current stressors in life and needs formal assessment by a mental health care provider with experience in adolescent psychiatry. (Option 1) Giving false reassurance (eg, "Everything is going to be alright.") is nontherapeutic communication as it implies that there is no cause for concern and provides no specific information about this client's condition. (Option 4) Asking judgmental questions (eg, "Why didn't you bring your child in sooner?") is nontherapeutic as it may cause the client's parents to be defensive, thereby hampering communication. Educational objective: Providing relevant information, using empathetic statements, communicating with broad openings, and asking relevant questions are forms of therapeutic communication. These methods foster trust, allow expression of feelings, and elicit important information to assist with decision making.

A client with Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor. Which of the following initial responses by the nurse are appropriate? Select all that apply. 1. Administer a dose of prescribed PRN haloperidol before the client's behavior escalates further. 2. Inform the client that the health care provider will be notified about the inappropriate behavior. 3. Obtain another plate of food and ask the unlicensed assistive personnel to feed the client. 4. Redirect the client from the table to assist in folding napkins for the following day's meals. 5. Use direct eye contact, smile, and say to the client, "I can see that you are upset; you are safe here." CORRECT: 4 and 5 Clients with Alzheimer disease (AD) often exhibit behavioral problems (eg, agitation, resisting care) due to cognitive decline. Behavioral management techniques include: Acknowledgement of the client's emotions; this reduces feelings of isolation and being misunderstood (Option 5) Reassurance that the client will be kept safe from harm Distraction (eg, photographs, music, television) to divert the client's attention Redirection to simple tasks (eg, folding towels/napkins, stacking plates) (Option 4) Antipsychotic medications increase mortality in clients with dementia and should be used only as a last resort.

Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: 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. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance Lanugo (fine terminal hair) can be seen in extreme cases

Additional nursing interventions for the client at high risk for suicide include the following: Removing sharp and other potentially harmful objects (eg, belts, metal eating utensils, ties, glass items) from the client's environment Making sure the client swallows medications Supervising the client during meals Placing the client in a semiprivate room near the nurses' station (to reduce social isolation and allow easier access to the client) Making rounds at irregular intervals for the client who does not need constant observation, as well as at shift changes and when staff is unusually busy Encouraging the client to express feelings, especially anger Having an open and honest conversation with the client about changing suicide risk

Automatic or cliché responses (eg, it takes time to deal with losses) are nontherapeutic as they limit discussion and expression of the client's experience and emotion.

By changing the subject, the nurse is attempting to redirect the conversation away from the client's desire to talk about death; this does not promote a therapeutic relationship.

Displacement is an ego defense mechanism that involves transferring uncomfortable feelings, emotions, or impulses about one person or situation to a substitute person or situation. for example...client leaves a stressful family meeting and immediately begins to verbally abuse a roommate Projection involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. An example is a husband with thoughts of infidelity who then accuses his wife of being unfaithful. think displacement as actual anger on to someone or something else...projection is a thought and u projecting that vile thought onto someone.

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).

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) SOILED or unsuitable for the weather not out of style clothing is select

Posttraumatic stress disorder (PTSD) is a reaction to a traumatic or catastrophic event that is typically life-threatening to oneself or others. There are 3 categories of PTSD symptoms: Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis) Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could be trauma reminders, feeling detached and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling jumpy

Goals for client recovery alcoholics include: Expressing accountability for previous behavior, including how abusing alcohol has impacted personal life (Option 1) Using insight to face reality and overcome rationalization and projection Using coping skills (eg, support groups, relaxation techniques) to improve reactions to stressful situations (Option 5) Setting goals for personal growth and self-worth development and using nonchemical alternatives (eg, fitness training) for stress relief (Option 4) Maintaining abstinence from alcohol consumption

A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today...they are so angry with me." Which of the following is the best response by the nurse? 1. "Do you need something to help you calm down?" [3%] 2. "Don't pay any attention to the voices. Let's go into the dayroom." [4%] 3. "The voices are not real. Tell them to go away." [8%] 4. "What are the voices saying to you?" [83%] Correct 4 The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following: Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) Not arguing with or challenging the client about the hallucinations Directing the client to a reality-oriented topic of conversation or activity (Option 1) An antianxiety medication may be needed if the voices are causing this client to become increasingly distressed. Assessment is needed before choosing this option. (Option 2) This choice dismisses this client's concerns about the nature of the voices. (Option 3) Telling the voices to "go away" (voice dismissal) is a technique that some clients find effective in management of hallucinations. It is not the priority nursing action in this client. Educational objective: It is important for the nurse to initially explore the content of a client's hallucinations to assess the risk for harm and/or injury and determine appropriate interventions. The nurse can tell the client that the nurse knows the voices are real to the client but are not heard by the nurse. The client with hallucinations should be directed to reality-oriented activities rather than to further discussion of the content of the hallucinations.

If child abuse is suspected, the nurse should obtain a detailed history, perform a physical examination, and report signs of abuse. Parent-child interaction should be examined closely, and any inconsistencies between a parent's report and the actual findings should be documented.

The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? Select all that apply. 1. Assist the client to identify circumstances that increase anxiety 2. Provide positive feedback when the client attends a group activity 3. Refrain from judgmental comments about counting magazines 5. Teach the client how to use the technique of thought stopping Obsessive-compulsive disorder is characterized by persistent, intrusive thoughts (obsessions) and behaviors performed ritualistically and repetitively to try to reduce anxiety (compulsions). Nursing care includes assisting the client to identify anxiety-producing situations, allowing time for the ritualistic behavior (initially), remaining nonjudgmental, offering positive feedback, and providing cognitive-behavioral therapy.

Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that people's motives are malicious and assume that others are out to exploit, harm, or deceive them. Because these clients do not trust other people, they have an intense need to control them and their environment.

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.

Long-term care also includes community services such as meals, adult day care, and transportation services. These services include the adult staying at home and having someone come in to care for their loved ones etc.

A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake most of the night, feel exhausted, and do not know what to do." What is the best response by the nurse? correct: our social worker can discuss long term care options with you incorrect: Keeping a client with Alzheimer disease awake during the day is a behavioral strategy that may reduce the risk of sundowning (increased confusion and agitation in the evenings). However, this response does not address the caregiver's stress and exhaustion. This caregiver is experiencing high levels of stress and exhaustion related to caring for the client; without help, the caregiver could easily experience burnout. A social worker can provide information on resources and services for assistance and support; these include adult day programs, in-home assistance, visiting nurse services, and home-delivered meals. The social worker can also provide the names of agencies that seek the support of others in similar situations (eg, local chapter of the Alzheimer's Association).

Parents of newborns diagnosed with Down syndrome or other developmental disabilities may experience shock or disbelief along with a wide array of emotions. Nurses should be supportive by using therapeutic communication techniques that encourage the family to talk about what they are experiencing and/or feeling.

Clients with social anxiety disorder have an excessive, persistent fear of social or performance situations involving strangers and the possibility of criticism, embarrassment, humiliation, and rejection. The fear of the situation(s) causes severe anxiety and avoidance. Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public, and giving a speech. The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and blushing. When asked this question the person most at risk or best example would be someone performing or representing large crowds etc since they have no control.

Signs & symptoms of major depression - SIGECAPS Sleep (increased or decreased) Interest deficit (anhedonia) Guilt (worthless, hopeless) Energy deficit Concentration deficit Appetite (increased or decreased) Psychomotor retardation or agitation Suicidality

The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self-inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the best response by the nurse? 1. "Are you still going to take your business trip?" [2%] 2. "It sounds like you are having a difficult time coping with your partner's behavior." [39%] 3. "Your partner is most likely doing it for attention, so it's best to just ignore it." [1%] 4. "Your partner needs to be seen in the clinic today." [56%] Correct answer 4 Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a suicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior. (Options 1 and 3) The priority is for the client to be evaluated at the clinic due to the diagnosis and risk for suicide. The partner's response to the client's behavior can be discussed later. (Option 2) This is not the priority response; it focuses on the partner's needs rather than the client's. Educational objective: Clients with borderline personality disorder are at very high risk for suicide. Suicidal gestures and attempts must be taken seriously and evaluated for suicidal intent.

Some illicit substances (eg, marijuana, LSD, PCP) have been reported to cause episodes of severe, acute psychosis. Some clients will never experience another episode of psychosis. However, in rare cases, illicit substances may trigger a genetic predisposition to development of a mental illness such as schizophrenia. There is no way to establish the long-term prognosis.

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder? Agoraphobia is characterized by intense anxiety about being in a situation from which there may be difficulty escaping in the event of a panic attack. A person with agoraphobia may avoid open spaces, closed spaces, riding in public or private transportation, going outside the home, bridges/tunnels, and crowds.

The priority nursing action for a client exhibiting anxiety is to intervene in a manner that helps make the client feel more at ease. Delusions are fixed, false beliefs; challenging a client's delusional content system will increase the client's anxiety and will not change the client's beliefs.

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.

The clinic nurse reviews telephone messages left by 4 clients. Which client is the priority to call back first? 1. Client recovering from opioid addiction having cravings after losing job [0%] 2. Client with schizophrenia hearing voices advising to harm a neighbor CORRECT!!!!!! 3. Parent of a client with conduct disorder who refuses to leave a locked room [0%] 4. Spouse of a client with depression reporting the client is threatening suicide [43%] Auditory hallucinations are the most common form of hallucination, noted by falsely perceived sounds, most often in the form of voices. Command hallucinations are a specific type of auditory hallucination, during which voices instruct the client to perform specific actions, often demanding harm to the client or others. Clients who are alone and experiencing command hallucinations that are homicidal or suicidal in nature require immediate intervention to ensure the safety of themselves and others (Option 2). (Option 1) A client experiencing addiction cravings needs assistance but is not a priority over a client with command hallucinations demanding harm to others. (Option 3) Parents of clients with conduct disorder need guidance and training to appropriately respond to problem behavior; however, this is not an immediate safety risk. (Option 4) A spouse calling about a suicidal client is not the first priority; the client is not alone, and the spouse can call others for help (eg, police, suicide hotline) if necessary while awaiting the nurse's return call. This should be the second returned call. *Educational objective: A client who is alone with command hallucinations that are homicidal or suicidal in nature requires immediate intervention to prevent harm. Clients who are homicidal or suicidal but are with another person should be addressed after those who are alone.*

antisocial people: disregard rules, irresponsible, blames others, key thing is for the nurse to set firm limits and rules. do not confront them.

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? Select all that apply. Codependent behaviors are those that allow the codependent person to maintain control by fulfilling the needs of the addict first. Behaviors such as keeping the addiction secret, suffering physical or psychological abuse from the addict, not allowing the addict to suffer the consequences of actions, and making excuses for the addict's habit are hallmarks of codependency. If the addict isn't happy, the codependent person will try to make the addict happy. Codependent persons will focus all their attention on others at the expense of their own sense of self. Codependent spouses, friends, and family members keep the client from focusing on treatment; this behavior is counterproductive to both themselves and the client. examples include getting up early and keeping the kids from being too loud in the morning when u know darn well that man is drunk like a skunk in the morning, blaming your work on why he drinks, rescheduling your entire life just to baby the alcoholic mess in your bed!!

Symptoms of ADHD usually continue into adulthood; current research indicates that children do not outgrow the condition. However, individuals with ADHD learn to cope with and manage the symptoms and achieve their full potential, leading healthy and satisfying lives. They may move into a condition of being "recovered," but this is usually a dynamic and ongoing state. things you should do for kids with ADHD -Children with ADHD are usually overwhelmed and overstimulated when faced with numerous choices. Offering 2 choices will help organize and structure the child's decision-making process. - There are legal mandates requiring school-based services and accommodations for children with ADHD. However, some teachers and/or school systems may not be as familiar with these requirements; it is important that parents of children with ADHD advocate for these individualized services. - Parents and caregivers should make direct eye contact and focus on their children when giving instructions. Other distractions should be minimized to avoid overstimulation. so don't multi task when talking to a kid with ADHD

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 your child's usual behavior at home?" 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?" 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.

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 Correct 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.

The nurse cares for a client newly diagnosed with acute stress disorder following a traumatic event. Which of the following communications by the nurse are appropriate? Select all that apply. 1. "How has this situation affected your relationships with family and friends?" 2. "It is important to focus on coping strategies and not dwell on the event." 3. "It is normal to experience difficult symptoms after a traumatic event." 4. "Please tell me about your current use of alcohol and any drugs." 5. "Share with me any thoughts or plans of self-harm that you have had." Correct answer 1,3,4,5 Acute stress disorder (ASD) occurs following a traumatic or extremely stressful event. ASD is characterized by intrusive memories of the event, negative mood, dissociative symptoms (eg, altered sense of reality), and arousal and reactivity symptoms (eg, hyperactive sensory state, sleep disturbances, difficulty concentrating, easily startled). If these symptoms continue beyond a month after the event, the diagnosis becomes post-traumatic stress disorder. Nursing interventions for a client with ASD include: Assessing for ideas and plans to commit self-harm (Option 5) Assessing for ineffective coping (eg, use of drugs and alcohol) (Option 4) Assessing impact of ASD on the client's job performance, relationships, sleep pattern, and ability to perform activities of daily living (Option 1) Explaining that feelings and/or symptoms occurring after traumatic events are normal, as this can help alleviate the client's anxiety (Option 3) Exploring coping strategies used in previous stressful situations (Option 2) The client should be encouraged to discuss the traumatic event. As part of the debriefing process, the nurse should acknowledge and validate the associated feelings and behaviors. Educational objective: Clients with acute stress disorder (ASD) should be encouraged to discuss the traumatic event and explore the associated feelings. The nurse should validate the client's feelings; assess risk for self-harm and ineffective coping (eg, drug and alcohol use); and evaluate the impact of ASD on the client's sleep, occupation, and relationships.

anorexics NO food diary bulimics YES 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.

The nurse is caring for a client admitted with abdominal pain, who has been diagnosed with somatic symptom disorder after a thorough evaluation finds no medical cause for the symptoms. Which intervention should the nurse include in the plan of care? 1. Advocate for an elimination diet to identify the cause of the symptoms [31%] 2. Limit time spent discussing physical symptoms with the client [41%] 3. Reinforce negative examination results when pain medication is requested [17%] 4. When abdominal pain is mentioned, remind client that it is not real [9%] Correct: 2 Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight. To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: Redirect somatic complaints to unrelated, neutral topics Limit time spent discussing physical symptoms (Option 2) To promote insight and healthy coping mechanisms, the nurse should assist the client to: Identify secondary gains (eg, increased attention, freedom from responsibilities) Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member) Incorporate appropriate coping strategies (eg, relaxation training, physical activity) (Option 1) An elimination diet would increase the client's focus on the symptoms and is inappropriate, as physiological causes have already been ruled out. (Option 3) The client's symptoms are real despite the lack of diagnostic findings. The nurse should administer analgesics as prescribed. (Option 4) Disputing the validity of the client's symptoms may increase the client's stress level and exacerbate symptoms. Educational objective: Somatic symptom disorder occurs when stress causes medically unexplainable physical symptoms that disrupt daily life. Nursing interventions include limiting discussion of symptoms and identifying secondary gains, factors that intensify symptoms, and coping strategies.

autistic patient -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. -Again the PRIORITY for an autistic patient is setting that schedule -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. -do not give them a lot of toy or too many visitors bc we want to avoid over stimulation

The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the priority nursing action? Give the child a written schedule of daily activities most important nursing intervention in caring for a child with ADHD is providing a structured, consistent, and organized environment. A written schedule of activities will remind the child what to expect at any given time. The key nursing intervention to help the child with ADHD adjust to hospitalization is providing a calm, structured, organized, and consistent environment. A written chart or list of daily activities will help remind the child of what to expect and what will happen at any given time. limiting visitors would also be implemented but it is not the priority

ECT - effective in helping severe depression, when clients pose a severe threat to themselves and it is not safe to wait until medications take effect. ECT is also used in clients who have not responded to medication or cannot tolerate side effects. -During ECT, the client is treated with pulses of electrical energy through electrodes applied to the scalp; -General anesthesia and a skeletal muscle relaxant are administered to minimize the motor seizure and prevent musculoskeletal injury. -The client feels nothing from the procedure, but confusion and memory loss are common side effects. -The usual course of acute therapy is 6-12 ECT treatments performed 2-3 times a week. Response to ECT can be dramatic and life-saving. -Maintenance therapy (treatment at 1- to 8-week intervals) can continue on a long-term basis to help prevent relapses. -Medication therapy is often given in combination with ECT and is associated with improved outcomes.

The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client's place of worship. What is the priority nursing action? answer: Encouraging the client to talk about the trauma rational: The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety. The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to discuss the trauma at their own pace. The nurse should also use active listening as a therapeutic approach to build trust and allow clients to vent. This will assist in decreasing their feelings of isolation. The nurse can also guide the client in identifying event details that are most troubling and trigger a sense of loss of control. The effectiveness of the client's coping mechanisms can be identified, and alternate strategies to replace maladaptive ones can be explored

Any client who cannot definitively say that currently he/she is not suicidal (shrugs shoulder when asked, looks away, plays with their phone, ignores you) 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. It is wise to do the one to one supervision. 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)

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? These decisions are challenging tell me your souse beliefs end of life stuff ... do not pass the buck unless you really have to!

An individual with obsessive-compulsive personality disorder is typically rigid and inflexible and has a need to control both internal and external experiences. A change in a schedule that is outside of the client's control could cause significant distress.

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessments would support this diagnosis? Select all that apply. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood Correct answer 1,2,4,5 Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). There are 3 categories of PTSD symptoms: Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (eg, rapid, pounding heart; gastrointestinal distress; diaphoresis) (Option 4) Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event (Option 2) Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of rage, persistent anger and/or fear, difficulty concentrating, hypervigilance, and exaggerated startle response (Options 1 and 5) (Option 3) Persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep. Educational objective: A person suffering from post-traumatic stress disorder experiences 3 categories of symptoms: reexperiencing the traumatic event, avoiding reminders of the trauma, and hyperarousal.

Caregiver role strain (CRS) is a caregiver's perception of the multifactorial difficulties associated with providing care to another person (usually a family member). The nurse should assess caregivers for signs of physical (eg, fatigue, insomnia, weight loss/gain), emotional (eg, depression, anxiety, anger), and social (eg, isolation, loss of support systems) problems. Monitoring caregivers for CRS is important, as it can have a significant negative impact on their health and well-being. Asking about the nature and requirements of providing daily care allows the caregiver to discuss the demands of providing care and helps the nurse understand stressors and unmet needs (Option 2). This type of inquiry is a therapeutic response that encourages verbalization of thoughts, feelings, and concerns. Assessment of caregiving challenges also helps to identify opportunities for assistance (eg, skills training, support groups) and community resources (eg, home health care, food/nutrition services).

Voicing doubt is a therapeutic communication technique that allows the nurse to dispel misconceptions or delusions without directly confronting the client's beliefs. for example "It is doubtful the president is out to get you"

ECT Electroconvulsive therapy (ECT) induces a generalized seizure by passing an electrical current through electrodes applied to the scalp. Although the exact mechanism is unknown, 15-20-second seizures are proven effective in treating mood disorders (eg, major depression, bipolar disorder) and schizophrenia. Client teaching includes: NPO status is required for 6-8 hours prior to treatment except for sips of water with medications (Option 4). Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure. Driving is not permitted during the course of ECT treatment (Option 2). Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT (Option 3). Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway, assessing mental status, and providing frequent reorientation during periods of postictal confusion. (Option 1) Valproic acid (Depakote) is an anticonvulsant that is also prescribed for bipolar disorder; therefore, it would prevent the therapeutic effect of ECT. Any prescribed anticonvulsants should be discontinued prior to ECT. Educational objective: Electroconvulsive therapy (ECT) uses an electrical current applied to the scalp to induce a generalized seizure in an anesthetized client. Prior to the procedure, the client should be NPO and not take anticonvulsant medications. Temporary confusion and memory loss are common after the procedure. Clients should be instructed not to drive during the course of ECT treatment.

When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal (Option 2).

Clients with catatonic schizophrenia are unable to meet their own needs for fluids, food, movement, and elimination and need assistance in performing basic activities of daily living. However, a priority diagnosis is deficient fluid volume.

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)

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 Correct 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 agitation, fever, tachycardia, hypertension, and diaphoresis.

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 clients 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 Correct 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.

In contrast to delirium, dementia is gradual in onset and causes an irreversible and progressive cognitive decline. Remote memory is spared initially and there is no impairment of consciousness until the late stages of the disease. Psychosis does not have an acute onset. Clients with this condition are usually oriented but have auditory (not visual) hallucinations.

Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The nurse now evaluates new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The nurse suspects which condition in this client? Delirium bc...New-onset confusion regarding sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy can be manifestations of delirium in a critically ill client who was previously alert and oriented.

A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse? 2. "Let's go back to your room and look for your headband together." [58%] CORRECT 3. "There is no oil coming out of your head." [32%] The client, while delusional, is exhibiting signs of anxiety. The priority action for the nurse is to intervene in a manner that will assist in reducing the client's unease. The headband is part of the client's delusional system; it is highly likely that the client will continue to be apprehensive until the headband or substitute is found. Offering to help the client look for the headband conveys a sense of caring and helps establish a trusting relationship. Once the client has calmed down, the nurse will minimize any conversation about the "crack" and the "oil" and can direct the client to reality-oriented activities. Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion. Categories of delusions include the following: Persecutory - client thinks others are "out to get me" Ideas of reference - common events refer specifically to the client Grandiose - client has the perception of special importance or powers that are not realistic Somatic - false ideas about bodily functioning *Nursing interventions include the following:* Not arguing or challenging the belief Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system.* DO NOT CHALLENGE THEIR BELIEF

hallucinations -the best response to them presents reality and acknowledges how the client may be feeling. "I don't see anything, but I understand that what you are seeing may be very upsetting to you." "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real." "I know the voices seem real to you and may be scary. I do not hear the voices."

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.

mnemonic SAD PERSONS uses known risk factors and the concept of their accumulation to help predict who is at a higher risk of committing suicide. S Sex (men kill themselves more often than women; women make more attempts) A Age (teenagers/young adults, age >45) D Depression (and hopelessness) P Prior history of suicide attempt E Ethanol and/or drug abuse R Rational thinking loss (hearing voices to harm self) S Support system loss (living alone) O Organized plan; having a method in mind (with lethality and availability) N No significant other S Sickness (terminal illness)

A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse; I know you'll be a good sport and give me a pass." What is the best response by the nurse? 1. "The gift shop is not even open right now." 2. "I guess the day shift staff needs to be reminded of the rules." 3. "What do you want to get from the gift shop?" 4. "You do not have privileges for leaving the unit. I cannot give you a pass." CORRECT: 4 Manipulative behaviors, such as attempts at staff splitting, are common in clients with borderline and antisocial personality disorders, substance abuse problems, somatic symptom disorder, and bipolar disorder (during the manic phase). The manipulative behavior is aimed at gaining control/power over a person/situation or for material gratification. Clients manipulate by flattery or by pitting staff members against each other. They may "tell" on a staff member or act in a way to give the impression of sincerity and caring. Nursing interventions for manipulative behaviors include: Setting limits that are realistic, nonpunitive, and enforceable Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors Enforcing all unit, hospital, or center rules (Option 4) Ensuring consistency from all staff members in enforcing set limits (Option 1) Telling the client the gift shop is closed does not address the client's manipulative behavior. (Option 2) Believing the client's statement is not appropriate as it will only reinforce the client's manipulative behavior. (Option 3) Asking the client the reason for going to the gift shop ignores the fact that the client is trying to break the rules. Educational objective: Clients who want to gain power or control over a situation or desire material gratification may use manipulative behaviors (eg, staff splitting). Nursing interventions include setting behavioral limits; using a neutral, matter-of-fact tone when discussing rules and consequences of unacceptable behavior; and ensuring consistency from staff members in enforcing limits.

no food logs for anorexic pts If a client shows possible signs of abuse or neglect, the priority is to remove any sources of immediate danger (eg, suspected abuser) from the room to prevent further harm. Assessments and further interventions can occur after ensuring the client's safety.