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A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as:
1. echolalia
2. an idea of reference
3. a delusion of infidelity
4. an
auditory hallucination
an idea of reference
A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?:
1. echolalia
2. waxy flexibility
3. depersonalization
4. thought withdrawal
waxy flexibility
The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?:
1. auditory hallucinations
2. delusions of grandeur
3. poor personal hygiene
4. psychomotor agitation
poor personal hygiene
A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question:
1. "How long has the voice been directing your behavior?"
2. "Does what the voice tell you to do frighten you?"
3. "Do you recognize the voice speaking to you?'
4. "What is the voice telling you to do?"
"What is the voice telling you to do?"
A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?:
1. powerlessness
2. social isolation
3. risk for suicide
4. compromised family coping
risk for suicide
A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse?:
1. "Are you having thoughts of suicide?"
2. "I am not sure I understand what you are trying
to say."
3. "Try to stay hopeful. Things have a way of working out."
4. "Tell me more about what interested you before you became depressed."
"Are you having thoughts of suicide?"
A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply:
1. imbalanced nutrition: more than body requirements
2. disturbed
thought processes
3. sleep deprivation
4. chronic confusion
5. social isolation
disturbed thought processes
sleep deprivation
The plan of care for a patient in the manic state of bipolar disorder should include which interventions? Select all that apply:
1. touch the patient to provide reassurance
2. invite the patient to lead a community meeting
3. provide a structured environment for
the patient
4. ensure that the patient's nutritional needs are met
5. design activities that require the patient's concentration
provide a structured environment for the patient
ensure that the patient's nutritional needs are met
The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply:
1.
channeling excessive energy
2. reducing guilty ruminations
3. instilling a sense of hopefulness
4. assisting with self-care activities
5. accommodating psychomotor retardation
instilling a sense of hopefulness
assisting with self-care activities
accommodating psychomotor retardation
Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply:
1. maintain arm's-length, one-on-one direct observation at all times
2. check all items brought by visitors and remove risk items
3. use plastic eating utensils; count utensils upon collection
4. remove the patient's eyeglasses to prevent self-injury
5. interact with the patient every 15 minutes
maintain arm's-length, one-on-one direct observation at all times
check all items brought by visitors and remove risk items
use plastic eating utensils; count utensils upon collection
manic depression =
bipolar
A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?:
1. discourage rest periods during the daytime
2. instruct family to avoid visiting during mealtimes
3. offer 3 or 4 large meals/day
4. give the client extra time to communicate needs
ANSWER:
give the client extra time to communicate needs
RATIONALE:
clients who have vegetative signs of depression have slowed thought processes and might take extra time to reply to questions or to verbalize thoughts
A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?:
1. temporary memory loss is the most common adverse effect of ECT
2. medications are given to prevent seizure activity during ECT
3. the greatest risk of ECT is brain damage
4. ECT is effective in the treatment of substance use disorders
temporary memory loss is the most common adverse effect of ECT
A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?:
1. encouraging decision-making
2. giving the client choices of activities
3. playing a game of chess with the client
4. spending time sitting with the client
ANSWER:
spending
time sitting with the client
RATIONALE:
-this option uses the therapeutic communication tool of being silent
-because clients who have depression frequently have suicidal tendencies, spending time with the client will provide safety
A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?:
1. "You really need to follow the rules of the unit and get out of bed."
2. "If you do not get out of bed you will not receive your meal."
3. "I will help you get ready and then you can rest after activities."
4. "You should rest until you feel able to join the group."
ANSWER:
"I will help you get ready and then you can rest after activities."
RATIONALE:
this statement shows caring by the nurse and provides for a balance between
activity and rest, which is an appropriate intervention for the client who has depression
A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?:
1. sit with the client and offer simple, direct information
2. have the client attend group therapy immediately
3. explain the unit policies to the client and answer any questions he might have
4.
take the client on a tour of the unit and introduce him to all the staff members on duty
sit with the client and offer simple, direct information
A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for Buproprion. Which of the following statements by the client indicates understanding of the teaching?:
1. "I may develop a slow heartbeat while taking
Bupropion."
2. "I can drink one glass of wine with dinner each day while taking Bupropion."
3. "I may not notice a lifting of my mood for at least 2 weeks."
4. "I should watch for increased salivation and drooling while taking Bupropion."
"I may not notice a lifting of my mood for at least 2 weeks."
A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further evaluation?:
1. "I had a great trip to the Smokey Mountains."
2. "Going back to work has been okay."
3. "I just don't like going to the movies like I used to."
4. "I can't wait to have my family together next weekend."
ANSWER:
"I just don't like going to the movies like I used to."
RATIONALE:
this statement indicates the client is having difficulty enjoying activities that were
previously pleasurable and requires further evaluation
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm really feeling down and don't want to talk to anyone right now." Which of the following responses should the nurse make?:
1. "It might help you feel better if you talk about it."
2. "I'll just sit here with you for a few minutes then."
3. "I
understand. I've felt like that before, too."
4. "Why are you feeling so down?"
ANSWER:
"I'll just sit here with you for a few minutes then."
RATIONALE:
-this therapeutic response is an example of offering self
-by sitting with the client, the nurse demonstrates caring and concern, and shows the client that the nurse is available if the client wants to talk
A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?:
1. "Everyone feels better after showering."
2. "You must be getting better. You look great!"
3. "I see you have done some grooming today."
4. "Why are you all dressed up today? Is it a special occasion?"
ANSWER:
"I see you have done some grooming today."
RATIONALE:
this response is open-ended and therapeutic because it offers the client recognition of positive behavior and encourages further discussion
A nurse in an acute mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?:
1. encourage family to take the client out of the facility for short periods of time
2. reward the client for her change in behavior
3. monitor the client's whereabouts at all time
4. ask the client why her behavior has changed
ANSWER:
monitor the client's whereabouts at all time
RATIONALE:
clients who have depression and exhibit a sudden change in behavior are at risk for suicide and suicide precautions
should be included in the plan of care
A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?:
1. ask the client if she has a plan to commit suicide
2. recognize the attempt at manipulation and escort the client back to her
activity
3. assist the client to her room allowing her to rest before resuming activity
4. notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone
ANSWER:
ask the client if she has a plan to commit suicide
RATIONALE:
the nurse should take seriously all statements regarding suicide
A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates an understanding of the teaching?:
1. "I need to make a voluntary choice to stop feeling depressed."
2. "I can cure my depression by thinking positive thoughts."
3. "I will attend psychotherapy to help manage my depression."
4. "I will plan on my antidepressant taking 3-5 days to be effective."
ANSWER:
"I will attend psychotherapy to help manage my
depression."
RATIONALE:
psychotherapy is an effective treatment for the long-term management of depressive disorders
A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?:
1. being married
2. pregnancy
3. male gender
4. chronic illness
chronic illness
A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse take prior to the scheduled ECT? (Select all that apply):
1. request an ECG
2. witness the informed consent
3. check the client's blood pressure
4. obtain a serum parathyroid hormone level
5. obtain a urine specimen
-request an ECG (a baseline ECG allows the provider to identify cardiac changes that can occur during ECT)
-witness the informed consent (required prior to ECT unless the client is receiving involuntary treatment)
-check the client's blood pressure (a baseline blood pressure allows the provider and nurse identify cardiac stress that can occur during ECT)
A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?:
1. a semi-private room across from the day room
2. a private room across the nurse's station
3. a private room across from the exercise room
4. a semi-private room across from the snack area
ANSWER:
a private room across the nurse's station
RATIONALE:
a private room decreases stimuli for the client and does not subject another client to his overactive behavior
A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings is this client exhibiting?:
1. flight of ideas
2. grandiosity
3. reality testing
4. derealization
grandiosity
flight of ideas =
refers to continuous, rapid speech which abruptly changes from topic to topic
grandiosity =
refers to the client's belief that he has special abilities or great powers
reality testing =
refers to the client's ability to recognize and correct alterations in thinking
derealization =
refers to the client's belief that the environment is unreal or distant
A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?:
1. provide a stimulating environment
2. have consistent unit routines
3. discourage daytime napping
4. schedule daily seclusion times
have consistent unit routines
A nurse in an acute mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?:
1. the client has begun playing basketball with several other clients during the past month
2. the client identifies with problems expressed by other clients
3. the client's behavior has become impulsive in the past few weeks
4.
the client states that she wants to go home to be with her children and partner
ANSWER:
the client's behavior has become impulsive in the past few weeks
RATIONALE:
the presence of impulsive behavior is a primary risk factor for suicide and clients who have mania can act in a manner which is hostile, aggressive, and impulsive
A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?:
1. Fluvastatin
2. Carbamazepine
3. Lorazepam
4. Propranol
ANSWER:
Carbamazepine
RATIONALE:
-an antiseizure medication and mood stabilizer
-prescribed to treat and prevent mania in clients with bipolar disorder
A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (Select all that apply).
1. Paroxetine
2. Lithium
3. Donepezil
4. Valproate
5. Carbamazepine
-Paroxetine (antidepressant/SSRI)
-Lithium (used to treat mania and depression)
-Valproate (anticonvulsant/mood stabilizer)
-Carbamazepine (anticonvulsant/mood stabilizer)
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?:
1. "You are already too thin and exercise is not good for you. Go sit down somewhere and eat something."
2. "Come with me. Here is a milkshake to drink."
3. "We need
you to decide what activities you will do today."
4. "You will need to leave the dining room right now and go somewhere else to exercise."
ANSWER:
"Come with me. Here is a milkshake to drink."
RATIONALE:
-when working with a client who is experiencing mania, the nurse should provide short, firm, and concise directions
-an appropriate activity for the client is to accompany the nurse to a quiet place away from the clients who are trying to
eat
A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?:
1. reviewing the client's toxicology laboratory report
2. making a contract with the client for eating behvior
3. initiating suicide precautions
4. administering the Hamilton Depression Scale
ANSWER:
initiating
suicide precautions
RATIONALE:
client safety is the nurse's priority
A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply):
1. death of a parent at a young age
2. recent or impending move
3. low parental expectations
4. volunteering at a community center after school
5. sudden decline in school
performance
-death of a parent at a young age
-recent or impending move
-low parental expectations
-sudden decline in school performance
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station sat 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?:
1. "You are being unreasonable, and I will not call your doctor at this hour."
2. "Go back to your room, and I'll try to get in touch with your doctor."
3. "I can't call a doctor in the middle of the night unless it's an emergency."
4. "You must be very upset about something."
"You must be very upset about something."
A nurse is caring for a client who has bipolar disorder and is taking Lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?:
1. withhold the medication
2. prepare to administer Propranolol
3. administer the next dose as prescribed
4. plan to administer Levothyroxine
ANSWER:
withhold the medication
RATIONALE:
patient is displaying manifestations of toxicity
A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?:
1. "His favorite teacher committed suicide a few weeks ago."
2. "He has slept 9 hours each night for the past 2 years."
3. "He is very religious and attends services twice a week."
4. "He spends most of his time with his two school friends."
ANSWER:
"His favorite teacher committed suicide a few weeks ago."
RATIONALE:
adolescents are at risk for a "copycat" suicide if a peer or significant role model has recently committed suicide
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?:
1. watching a video with a group in the day room
2.
walking with the nurse in the courtyard
3. participating in a basketball game in the gym
4. joining a group discussion about a local election
ANSWER:
walking with the nurse in the courtyard
RATIONALE:
-clients who have bipolar disorder are prone to hyperactivity
-the nurse should provide activities that provide a way for the client to release physical energy, while avoiding situations that might provoke the client
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?:
1. implement the client's behavioral modification plan
2. document the size and location of the cuts
3. inspect the cuts for debris
4. administer a tetanus antitoxin
ANSWER:
inspect the cuts for debris
RATIONALE:
the
first action the nurse should take when using the nursing process is to assess the client, therefore inspecting the cuts is the first action
A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?:
1. place metal utensils on the client's metal tray
2. assign the client to a private room
3. inspect the client's personal belongings
4. tuck bedcovers over client's hands
and arms
inspect the client's personal belongings
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?:
1. the client's spouse reports that the client has recently gained weight
2. the client is dressed in all black
3. the client responds to questions with disorganized speech
4. the
client reports that voices are telling him to write a novel
ANSWER:
the client responds to questions with disorganized speech
RATIONALE:
clients who are experiencing acute mania exhibit disorganized speech such as a flight of ideas
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for Lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause Lithium toxicity?:
1. experiencing diarrhea
2. exercising moderately
3. increasing sodium intake
4. drinking green tea
experiencing diarrhea
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?:
1. a private room in a quiet location on the unit
2. a semi-private room with a roommate who has a similar diagnosis
3. a private room close to the nursing station
4. a seclusion room until the client's activity level becomes more subdued
ANSWER:
a private room in a quiet location on the unit
RATIONALE:
a private room in a quiet location is ideal for a client with mania
A nurse is caring for a client who has bipolar disorder. Which of the following actions by the nurse should the nurse interpret as displaying manic behavior? (Select all that apply):
1. talking in rapid, continuous speech
2. interacting with others in a flirtatious way
3. spending large sums of money
4. sleeping for long periods of time
5. dressing in black or grey clothing
-talking in rapid, continuous speech
-interacting with others in a flirtatious way
-spending large sums of money
A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide?:
1. substance use disorder
2. age greater than 45 years old
3. female gender
4. currently married
5. schizophrenia
-substance use disorder
-age greater than 45 years old
-schizophrenia
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?:
1. "You have a great deal to live for."
2. "It's not unusual for depressed people to feel that way."
3. "Why do you feel you are worthless?"
4. "You've been feeling that your life has no meaning."
"You've been feeling that your life has no meaning."
A nurse is caring for a client who has bipolar disorder and a new prescription for Valproate. Which of the following instructions should the nurse give the client about the use of this medication?:
1. thyroid function tests should be performed every 6 months
2. a pretreatment electroencephalogram (EEG) will be done
3. liver function tests must be monitored
4.
high serum sodium levels can cause toxic levels of Valproate
ANSWER:
liver function tests must be monitored
RATIONALE:
-pancreatitis, hepatic dysfunction, and thrombocytopenia are serious adverse effects occasionally associate with Valproate
-liver function tests should be monitored periodally
A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?:
1. turn on a dance video so the client can burn off excess energy
2. offer the client a low-calorie snack in return for stopping the behavior
3. take the client outside and sit with her in the garden area
4. observe the client closely for the development of aggressive behavior
ANSWER:
take the client outside and sit with her in the garden area
RATIONALE:
it
is appropriate to remove the client from the stimulating environment and to use instruction, rather than bargaining, to decrease the activity level
A nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. Which of the following statements by the clients indicate adaptive coping? (Select all that apply):
1. "I exercise aerobically three times a day for 30 minutes at a
time."
2. "I get 7 hours of sleep at night by skipping afternoon naps."
3. "I think about being on my favorite beach vacation when I get anxious."
4. "I tense and release my muscles, starting with my feet."
5. "I see the glass as half-full when it starts looking empty."
-"I get 7 hours of sleep at night by skipping afternoon naps."
-"I think about being on my favorite beach vacation when I get anxious."
-"I tense and release my muscles, starting with my feet."
-"I see the glass as half-full when it starts looking empty."
A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?:
1. "Do you think your anxiety is worse than everyone else's?"
2. "Tell me what has been happening lately."
3. "It doesn't appear as though you are feeling anxious."
4. "I think you should see a therapist."
"Tell me what has been happening lately."
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?:
1. "I plan to sit on a park bench for a few minutes each day."
2. "I can try participating in group therapy every week."
3. "I will join a book club in my neighborhood."
4. "I should avoid entering elevators
and other closed spaces."
ANSWER:
"I plan to sit on a park bench for a few minutes each day."
RATIONALE:
-agoraphobia is fear of being in places in which help may not be available
-this typically manifests as a fear of being outside alone
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms?:
1. reaction-formation
2. compensation
3. rationalization
4. suppression
ANSWER:
rationalization
RATIONALE:
the client is trying to justify his alcohol use by blaming his boss
A nurse in a mental health clinic is assessing a client who was brought by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?:
1. xenophobia
2. acrophobia
3. mysophobia
4. agoraphobia
ANSWER:
agoraphobia
RATIONALE:
-xenophobia is a fear of strangers
-acrophobia is a fear of heights
-mysophobia is a fear of dirt or germs
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?:
1. "It sounds like you're having a difficult time."
2. "Have you talked to your parents about this yet?"
3. "Why do you think you are so anxious?"
4. "How long has this been going on?"
ANSWER:
"It sounds like you're having a difficult time."
RATIONALE:
this
therapeutic response is an open-ended empathetic statement
A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan?:
1. contact the crisis counselor once a week
2. identify anxiety-producing situations
3. try to repress feelings of anxiety
4. eliminate stress and anxiety from daily life
ANSWER:
identify anxiety-producing situations
RATIONALE:
treatment for anxiety disorders includes helping the client recognize signs that her anxiety level is rising and the triggers that cause this type of reaction
A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?:
1.
attention-seeking conduct
2. mild difficulty problem solving
3. mild figeting
4. threatening behavior
ANSWER:
threatening behavior
RATIONALE:
the client experiencing severe anxiety can have feelings of confusion and impending doom
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?:
1. dissociation
2. introjection
3. regression
4. repression
ANSWER:
regression
RATIONALE:
this is an example of regression which is the mechanism of reverting to childlike or immature behaviors
A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply):
1. avoid eye contact to prevent escalation of anxiety
2. establish rapport with the client
3. identify the cause of the anxiety
4. validate the client's feelings
5. develop a flexible crisis intervention plan
-establish rapport with the client
-identify the cause of the anxiety
-validate the client's feelings
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?:
1. instruct the client to sit down and stop pacing
2. allow the client to pace alone until physically tired
3. have a staff member escort the client to her
room
4. walk with the client at a gradually slower pace
walk with the client at a gradually slower pace
A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?:
1. conversion
2.
projection
3. undoing
4. regression
ANSWER:
projection
RATIONALE:
projection is a defense mechanism in which the client refuses to acknowledge unacceptable personal characteristics and transfers feelings, thoughts, or traits onto another person
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?:
1.
protecting the client from injury
2. determining the cause of the client's anxiety
3. ensuring that the client feels safe
4. identifying the client's coping skills
protecting the client from injury
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?:
1. "Most clients with anxiety issues benefit from lying down."
2. "Come with me to an area where we can talk without interruption."
3. "Providers usually recommend relaxation exercises for clients who are as upset as you are."
4. "An antianxiety pill works best for situations like these."
ANSWER:
"Come with me to an area where we can talk without interruption."
RATIONALE:
with
this response, the nurse illustrates the therapeutic communication technique of offering herself
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?:
1. limit the amount of time available to interact with others
2. focus attention on meaningful
tasks
3. manipulate and control others' behaviors
4. decrease anxiety to a tolerable level
ANSWER:
decrease anxiety to a tolerable level
RATIONALE:
with OCD, obsessions give rise to anxiety, and the anxiety is then reduced by compulsive behaviors
A nurse is caring for a client who has generalized anxiety disorder and is taking Buspirone. Which of the following adverse effects should the nurse report to the provider?:
1. sweating
2. decreased appetite
3. discolored urine
4. hallucinations
ANSWER:
sweating
RATIONALE:
sweating is a manifestation of serotonin syndrome and should be reported to the provider
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?:
1. suggest that the client rest in bed
2. remain with the client for a while
3. medicate the client with a sedative
4. have the client join a therapy group
ANSWER:
remain with the client for a while
RATIONALE:
the nurse should not leave a client who has severe anxiety alone
A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for Alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering Alprazolam?:
1. the client states, "I see purple bugs crawling on the wall"
2. the client tells the nurse that he is too tired to attend the group meeting
3. the client tells the nurse he is a government agent
4. the client states, "my heart is pounding out of my chest"
ANSWER:
the
client states, "my heart is pounding out of my chest"
RATIONALE:
Alprazolam is a benzodiazepine used to treat anxiety
A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?:
1. remain with the client
2. provide a diverting activity
3. encourage verbalization of feelings
4. instruct the client to remember past coping mechanisms
ANSWER:
remain
with the client
RATIONALE:
the greatest risk to this client is self-injury from impulsive behavior
A nurse interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. The nurse should ask which of the following questions to determine the patient's ability to cope with this situation?:
1. "Don't you think you'll get through this in time?"
2. "To whom do you talk when you feel
overwhelmed?"
3. "Have you thought about rebuilding your home on the same site?"
4. "Would you like me to find a therapist for you to speak with?"
ANSWER:
"To whom do you talk when you feel overwhelmed?"
RATIONALE:
by asking this question, the nurse is assessing the client's support systems, which is an important factor in the client's ability to cope with the situation
A nurse is caring for a patient who gave birth to a stillborn baby. Which of the following is an appropriate statement by the nurse?:
1. "You probably want to hold your baby."
2. "I'll stay with you just in case you want to talk."
3. "I know how you must be feeling."
4. "It hurts now, but things will be better soon."
ANSWER:
"I'll stay with you just in case you want to talk."
RATIONALE:
this response indicates the nurse's interest in the client and a
desire to understand the client's feelings
A nurse on a med-surg unit is assessing a patient who sustained injuries 12 hrs ago following a motor-vehicle crasu. The blood alcohol level was 325 mg/dL. Which of the following findings indicate the client is experiencing alcohol withdrawal?:
1. somnolence
2. blood pressure 154/96 mm Hg
3. pinpoint pupils
4. blood glucose 210 mg/dL
ANSWER:
blood
pressure 154/96 mm Hg
RATIONALE:
a client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3 C (101 F)
A nurse is teaching a family member and a client who has a new diagnosis of Azheimer's disease and is to start taking Donepezil. Which of the following statements is to be included in the teaching?:
1. "Take this medication in the evening at bedtime."
2. "Expect this
medication to reverse the effects of Alzheimer's disease."
3. "If you miss a dose, double the next dose."
4. "You can crush this medication in applesauce."
ANSWER:
"Take this medication in the evening at bedtime."
RATIONALE:
the client should take this medication in the evening at bedtime for optimal effectiveness
A nurse is discussing a 12-step program with a patient who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information is to be included in the teaching?:
1. the program will help the client accept responsibility for his disorder
2. the client should obtain a sponsor before discharge for an increased chance of recovery
3. the client will need to identify individuals who have contributed to his disorder
4. the program will need a prescription from the client's provider prior to attendance
ANSWER:
the client should obtain a sponsor before discharge for an increased chance of recovery
RATIONALE:
the client-sponsor relationship has been shown to increase program attendance and the chances of recovery
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. She reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions is an appropriate action for the nurse to take?:
1. ask the client to identify the bomb in her room
2. initiate disaster protocols per facility policies and procedures
3. assess the client for evidence of a perceptual disturbance
4. convince the client that there is no bomb in her room
ANSWER:
assess the client for evidence of a perceptual disturbance
RATIONALE:
the nurse should assess the situation to determine if
the client is hallucinating or misperceiving external stimuli (experiencing illusions)
A nurse is admitting a client with major depression disorder and a NEW prescription for Tranylcypromine. Which OTC med that the patient reports taking should alert the nurse to a potential adverse reaction?:
1. Lansoprazole
2. Naproxen
3. magnesium hydroxide
4. Phenylephrine
Phenylephrine
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?:
1. delusions
2. neologisms
3. anhedonia
4. echopraxia
anhedonia
A nurse in an ED department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by her mother acknowledges the daughter's diagnosis?:
1. "She works so hard at ballet. Will she still be able to perform."
2. "She won't let me take the trash from her room. I'm concerned about what she has in there."
3. "She told me she was tired, so I did her chores for her today."
4. "She is happier with her appearance now that she's lost some weight."
ANSWER:
"She won't let me take the trash
from her room. I'm concerned about what she has in there."
RATIONALE:
the client may be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa
A nurse is assessing a patient who has major depressive disorder and has been receiving Amitriptyline for 1 week. Which of the following should the nurse expect?:
1. rapid improvement in affect within 30-60 mins after taking the
medication
2. greater risk of attempting suicide as affect and energy improve
3. onset of frequent loose stools
4. development of physiologic dependence on the medication
ANSWER:
greater risk of attempting suicide as affect and energy improve
RATIONALE:
an initial response to this medication can develop in 1 week
A nurse in a community health center is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following should the nurse include?:
1. repeatedly talks about the traumatic incident
2. sleeps excessively
3. experiences feelings of isolation
4. uses repetitive speech
ANSWER:
experiences feelings of isolation
RATIONALE:
clients who have PTSD often feel estranged and detached from others
A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization?:
1. weight loss 10% of total body weight in 3 months
2. potassium 3.8 mEq/L
3. temperature 35.6 C (96.1 F)
4. heart rate 54/min
ANSWER:
temperature 35.6 C (96.1 F)
RATIONALE:
severe hypotension (a temperature lower than 36 C (96.8 F) requires hospitalization
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first?:
1. Diazepam 5 mg IV bolus
2. Clonidine 0.1 mg transdermal patch
3. Naltrexone 380 mg IM
4. Bupropion 150 mg PO
ANSWER:
Diazepam 5 mg IV bolus
RATIONALE:
acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations
A client who has a diagnosis of depression is attending a group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. The patient does not respond when it is her turn. What is an appropriate action by the nurse before repeating the request to the patient?:
1. allow the client time to collect her thoughts
2. prompt the client to give a response
3. move on to the next client
4. offer the client a suggestion for a goal
ANSWER:
allow the client time to collect her thoughts
RATIONALE:
slowed response time is common in clients who have depression
A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?:
1. call the provider to obtain an immediate prescription for restraint
2. prepare to administer Benzodiazepine IM
3. call for a team of staff
members to help with the situation
4. check the client who was hit for injuries
ANSWER:
call for a team of staff members to help with the situation
RATIONALE:
the greatest risk is injury to the client and others
A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following teaching should the nurse include?:
1. have a family member present during treatment
2. increase fluid intake
3. change position slowly
4. wear sunglasses when outdoors
ANSWER:
wear sunglasses when outdoors
RATIONALE:
light therapy, or phototherapy, can cause eye strain and sensitivity to light
A client who has bipolar disorder is to be discharged home with a prescription for Lithium. Which statement indicates that the client has received effective teaching?:
1. "I should eat a regular diet with normal amounts of salts and fluids."
2. "I should discontinue the Lithium when I begin to feel better."
3. "I need to be careful to avoid becoming addicted to the Lithium."
4. "I can skip a dose of medication if my stomach is upset."
ANSWER:
"I should eat a regular diet with normal amounts of salts and fluids."
RATIONALE:
normal levels of sodium and
fluid need to be maintained to ensure adequate excretion of Lithium
A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?:
1. allowing a client to choose which unit activities to attend
2. attempting alternative therapies instead of restraints for a client who is combative
3. providing a client with accurate information about his
prognosis
4. spending adequate time with a client who is verbally abusive
ANSWER:
spending adequate time with a client who is verbally abusive
RATIONALE:
a guarantee that all clients receive equal care
A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse take?:
1. encourage the parents to avoid discussing the death with their
other children to protect their feelings
2. recommend each parent grieve in private to avoid hindering each other's healing
3. suggest forming a weekly support group for parents who have experienced the loss of a child
4. advise the parents to begin counseling if they are still grieving in a few months
ANSWER:
suggest forming a weekly support group for parents who have experienced the loss of a child
RATIONALE:
support groups are a
positive resource in the process of recovery for parents who have lost a child
A nurse in a mental health clinic is planning care for a client who has a new prescription for Olanzapine. Which of the following interventions should the nurse identify as the priority?:
1. advise the client to take frequent sips of water
2. instruct the client to avoid during initial therapy
3. consult a dietitian for a calorie-controlled diet plan
4.
recommend that the client exercise regularly
ANSWER:
instruct the client to avoid during initial therapy
RATIONALE:
the greatest risk to this client is injury resulting from drowsiness or dizziness
A nurse is preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse indicate? (Select all that apply):
1. occupational therapy
2. meal delivery services
3. speech therapy
4. physical therapy
5. home health services
-occupational therapy
-meal delivery services
-physical therapy
-home health services
A nurse is reviewing laboratory results for a client who has schizophrenia and is taking Clozapine. Which of the following values should the nurse identify as a contraindication for this medication?:
1. WBC 2,500/mm3
2. Hgb 11.5 mg/dL
3. platelets 150,00/mm3
4. RBC 3.5 million/mm3
ANSWER:
WBC 2,500/mm3
RATIONALE:
-Clozapine can cause agranulocytosis, which can be fatal
-the nurse should identify a WBC count below 3,000/mm3 as a possible manifestation of agranulocytosis
A nurse in an outpatient mental health setting is collecting a health history from a patient who is taking Paroxetine for depression. The patient is also taking herbal supplements. Which supplement has an adverse interaction with Paroxetine?:
1. St. John's wort
2. saw palmetto
3. echinacea
4. gingko
ANSWER:
St. John's wort
RATIONALE:
decreases the reuptake of serotonin (avoid medications that do the same)
A nurse is teaching a newly licensed nurse about nursing care plans for patients who have depressive disorders. Which of the following statements indicate an understanding of the teaching?:
1. "I will use the same plan of care and interventions for each client who has depression."
2. "Each individual nurse will develop a separate plan of care when managing clients who have depression."
3. "I will update the plan of care as a client's manifestations of depression change."
4. "An assistive personnel can use the
plan of care for client teaching."
ANSWER:
"I will update the plan of care as a client's manifestations of depression change."
RATIONALE:
the nurse should update the plan of care as a client's status and needs change
While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors are consistent with this condition?:
1. the client needs excessive external input to make everyday decisions
2. the client demonstrates a dedication to his job that excludes time for leisure activities
3. the client adheres to a rigid set of rules
4. the client has difficulty starting new relationships unless he feels accepted
ANSWER:
the client needs excessive external input to make everyday decisions
RATIONALE:
clients who have dependent personality
disorder need excessive input from others to make everyday decisions
A nurse is caring for a child who is taking Methylphenidate. The nurse should monitor the child for which adverse effect?:
1. weight gain
2. tinnitus
3. tachycardia
4. increased salivation
ANSWER:
tachycardia
RATIONALE:
the nurse should monitor the child for tachycardia, which is an adverse effect of Methylphenidate
A nurse is caring for a client with antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?:
1. controls anger outbursts to avoid being places in seclusion
2. no longer exhibits a fear of social or public situations
3. refrains from manipulating others to earn dining-room privileges
4. imitates the therapist's use of
relaxation technique
ANSWER:
refrains from manipulating others to earn dining-room privileges
RATIONALE:
-the goal of operant conditioning is to provide positive reinforcement in return for a desired behavior
-refraining from manipulative behavior is a desired response
A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?:
1. panic
2. moderate
3. severe
4. mild
ANSWER:
mild
RATIONALE:
the client will be able to concentrate and process information
A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?:
1.
confront the staff member
2. encourage the client to report the incident
3. document the incident in the client's health record
4. report the occurrence to the charge nurse
ANSWER:
report the occurrence to the charge nurse
RATIONALE:
it is the charge nurse and the nurse manager's responsibility to confront the staff member about her behavior toward the client
A nurse is caring for a patient who has attempted suicide and has alcohol use disorder. Which of the following statements indicates that the patient is using a positive coping mechanism?:
1. "I will limit my drinking to the weekends."
2. "I will stay in my room and avoid others when I'm feeling down."
3. "I will be dependent on others for the time being."
4. "I will attend daily group therapy sessions to practice relaxation techniques."
ANSWER:
"I will attend daily
group therapy sessions to practice relaxation techniques."
RATIONALE:
relaxation techniques decrease the risk for self-harm by decreasing stress, anxiety, and depression
A nurse is creating a plan of care for a patient who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions is to be included in the plan?:
1. document the client's behavior every 8 hr
2. limit the client's
fluid intake to 50 mL/hr
3. renew the prescription for the client every 4 hr
4. toilet the client every 4 hr
renew the prescription for the client every 4 hr
A nurse is planning care for a patient who has depression and has made frequent suicide attempts. Which statement indicates the patient has a decreased risk for suicide?:
1. "I'm relieved now that my financial affairs are in order."
2. "It is
easier to talk about my feelings now."
3. "Suddenly I have enough energy to do anything I want"
4. "Thank you for always taking such good care of me."
ANSWER:
"It is easier to talk about my feelings now."
RATIONALE:
when clients express their feelings, this indicates a positive treatment outcome
A nurse is reviewing routine labs for several patients who are taking lithium carbonate. Which of the following clients should be further assessed for findings indicating lithium toxicity?:
1. a client who has a fasting blood glucose of 80 mg/dL
2. a client who has a sodium level of 128 mEq/L
3. a client who has a BUN of 18 mg/dL
4. a client who has a potassium level of 3.6 mEq/L
ANSWER:
a client who has a sodium level of 128 mEq/L
RATIONALE:
renal excretion of lithium is decreased in the presence of a low sodium level
A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?:
1. amenorrhea
2. lanugo
3. cold extremities
4. tooth erosion
ANSWER:
tooth erosion
RATIONALE:
likely to have dental carries and tooth erosion caused by frequent exposure to gastric acid from vomiting
A nurse is planning care for a preschool-age child who has ADHD. Which interventions should be identified as the priority?:
1. decrease distractions during meal times
2. provide positive feedback when the child completes a task
3. clearly identify consequences for unacceptable behavior
4. remove unncessary equipment from the child's surroundings
ANSWER:
remove unncessary equipment from the child's surroundings
RATIONALE:
the greatest risk to the child who has ADHD is
injury from impulsive behavior and the decreased ability to perceive self-harm
A nurse is reviewing the chart of a patient who has dissociative amnesia. Which findings should the nurse expect?:
1. the client was seriously injured while under the influence of alcohol
2. the client has a history of panic attacks
3. the client chose to drop out of college a few months ago
4. the client works a stressful job at an international bank
ANSWER:
the client was seriously injured while under the influence of alcohol
RATIONALE:
a traumatic event that causes severe stress is a trigger for dissociative amnesia
A nurse is caring for a client who has a recent diagnosis of Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first?:
1. inability to recognize family members
2. chooses clothing that is inappropriate for the weather
3. exhibits a change in personality
4. frequently misplaces objects
frequently misplaces objects
Caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority?:
1. encourage expression of feelings
2. promote attendance at an assertiveness training group
3. assist the client to perform relaxation breathing
4. reduce environmental stimuli
ANSWER:
reduce environmental stimuli
RATIONALE:
-the greatest risk to the child and others is harm
-reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury
A nurse is assessing for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?:
1. the client is married
2. the client recently received a promotion at work
3. the client has COPD
4. the client is male
ANSWER:
the client has COPD
RATIONALE:
clients who have a medical illness are at an increased risk for the development of
depression
A nurse is admitting a patient who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?:
1. encourage the client to drink 125 mL of fluid each hour while awake
2. allow the client to eat independently in his room
3. weight the client twice weekly
4. measure the client's vital signs once each day
ANSWER:
encourage
the client to drink 125 mL of fluid each hour while awake
RATIONALE:
to maintain hydration
A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The patient with depression reports, "That man in my room never sleeps and he keeps me up, too." Which of the following is an appropriate action by the nurse?:
1. move the client who has bipolar disorder to a private room
2.
administer sleep medication to the client who has bipolar disorder
3. move the client who has severe depression to a private room
4. administer sleep medication to the client who has severe depression
ANSWER:
move the client who has bipolar disorder to a private room
RATIONALE:
clients who have bipolar disorder can disrupt the therapeutic milieu for other clients
A nurse is planning care for a patient who is to undergo electroconvulsive therapy (ECT). Which actions should be included in the plan of care?:
1. administer Phenyoin 30 min prior to the procedure
2. instruct the client to expect a headache following the procedure
3. place the client in four point restraints prior to the procedure
4. monitor the client's cardiac rhythm during the procedure
ANSWER:
monitor the client's cardiac rhythm during the procedure
RATIONALE:
the
seizure induced during ECT can stress that client's heart
A nurse is obtaining a mental health history for an older adult patient. Which of the following actions should the nurse plan to take?:
1. raise the pitch of the voice when speaking to the client
2. begin the interview by explaining the plan of care
3. interview the client in a private setting
4. ask the client to complete a detailed questionnaire
ANSWER:
interview the client in a private setting
RATIONALE:
the nurse should question clients in a private place when conducting interviews regarding client health
A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?:
1. "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat."
2. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."
3. "You don't want to look at yourself because you think you are fat."
4. "You and I can work together to overcome your fears of gaining weight."
ANSWER:
"You're saying that you think you
are fat and are using laxatives because you are afraid of gaining weight."
RATIONALE:
the nurse is using the therapeutic technique of summarizing to review the key points of the discussion
A nurse is planning prevention strategies for intimate partner abuse in the community. Which of the following strategies should the nurse include as a method of secondary prevention?:
1. provide teaching about the use of positive coping
mechanisms
2. establish screening programs to identify at-risk clients
3. refer survivors of intimate partner abuse to a legal advocacy program
4. organize rehabilitation therapy for clients who have experienced intimate partner abuse
ANSWER:
establish screening programs to identify at-risk clients
RATIONALE:
-example of secondary prevention
-helps take the necessary steps to address individual client needs
A nurse in a mental health clinic is caring for a patient who has bipolar disorder and reports that she stopped taking Lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the patient to stop taking the medication?:
1. sore throat
2. photophobia
3. hand tremors
4. constipation
ANSWER:
hand tremors
RATIONALE:
fine hand tremors are an
expected adverse effect of Lithium and can interfere with the client's ADLs, causing the client tor stop taking the medication
A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority?:
1. arrange one-to-one observation of the client
2. encourage interaction with the client's peers
3. administer
medication for depressive disorder
4. encourage the client to attend a support group
ANSWER:
arrange one-to-one observation of the client
RATIONALE:
-the greatest risk to the client is self-injury
-this answer promotes client safety
A nurse is a mental health facility is caring for a patient with schizophrenia. Which of the following places puts the patient at the greatest risk for self-directed injury or injuring others?:
1. inability to communicate with others
2. feelings of absence of self-worth
3. lack of motivation to perform daily tasks
4. command hallucinations
ANSWER:
command hallucinations
RATIONALE:
the command hallucinations includes voices telling him to hurt himself or others
A nurse is facilitating a community meeting for acute care of clients. One patient is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?:
1. tell the client that he must talk less or he will be removed from the meeting
2. ask group members to discuss their feelings about this client's monopolizing behavior
3. end the group meeting and take the client aside to discuss his behavior
4. focus on the other group members and ignore the client who is doing all the talking
ANSWER:
ask group members to discuss their feelings about this client's monopolizing behavior
RATIONALE:
-this intervention will validate other members' feelings toward this client in the scenario
-should also encourage group problem-solving
A home health nurse is assessing an older adult patient whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?:
1. increased confusion
2. sleep disturbances
3. cluttered environment
4. inappropriate dress
ANSWER:
inappropriate dress
RATIONALE:
clothing that is soiled or not appropriate for weather conditions is a possible indicator of neglect
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?:
1.
emotional lability
2. self-sacrificing
3. suspicious of others
4. grandiosity
ANSWER:
emotional lability
RATIONALE:
-the rapid transition from one emotion to another
-a primary feature of borderline personality disorder
A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the suspicion of delirium?:
1. slow onset
2. aphasia
3. confabulation
4. easily distracted
ANSWER:
easily distracted
RATIONALE:
extreme distractibility is a hallmark manifestation of delirium
A nurse is caring for a client who has schizophrenia and was prescribed a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer Benztropine 2 mg IM?:
1. shuffling gait
2. hypotension
3. decreased WBC count
4. blurred vision
ANSWER:
shuffling gait
RATIONALE:
Benztropine is used to treat parkinsonism manifestations, such as shuffling gait
A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client indicates successful use of guided imagery?:
1. "I consciously decrease my breathing rate when I feel anxious."
2. "I am riding my bike around the neighborhood every day."
3. "I find at least one positive thing in situations that upset me."
4. "I imagine myself lying on a quiet beach when I start to feel anxious."
ANSWER:
"I imagine myself lying on a quiet beach when I start to feel anxious."
RATIONALE:
envisioning oneself in a peaceful, calm environment enhances
relaxation and is an example of used guided imagery
A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue?:
1. an adolescent family member who questions parental authority
2. a family with three generations in the same household
3. older children who are responsible for their younger siblings
4. two adults and their children from
prior relationships in the same household
ANSWER:
older children who are responsible for their younger siblings
RATIONALE:
this is an example of enmeshed boundaries in which there are no distinctions between the roles of the family members
A nurse is caring for a client who is experiencing a panic attack. Which action should the nurse take?:
1. orient the client to person, place, and time
2.
assist the client with deep-breathing exercises
3. calm the client by using therapeutic touch
4. have the client sit alone in a quiet room
ANSWER:
assist the client with deep-breathing exercises
RATIONALE:
relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety
A nurse is planning care for a patient who has bipolar disorder and is experiencing mania. Which intervention should the nurse include in the plan of care?:
1. encourage the client to participate in group therapy
2. instruct the client to avoid napping during the day
3. offer the client high-calorie finger foods frequently
4. decrease the client's daily fiber intake
ANSWER:
offer the client high-calorie finger foods frequently
RATIONALE:
-the nurse should frequently offer the client high-calorie finger
foods that can be eaten while the client is on the go
-clients experiencing mania may be unable to sit down for meals and can experience weight loss and dehydration
A nurse observes a patient pushing on the locked unit door. Which statement should the nurse make?:
1. "It appears as though you would like to open the door."
2. "You will feel more comfortable after you've been here for a while."
3. "It is okay to not want to be
here."
4. "You really shouldn't be pushing on the door."
ANSWER:
"It appears as though you would like to open the door."
RATIONALE:
-this statement is an example of the therapeutic technique of making observations
-this technique encourages the client to notice the behavior so that she can describe thoughts and feelings related to that behavior
A charge nurse observes an assistive personnel (AP) slapping an older adult client. After moving the client to safety, which is the priority action?:
1. complete an incident report
2. determine if the client has been physically harmed
3. provide emotional support to the client
4. discipline the AP
ANSWER:
determine if the client has been physically harmed
RATIONALE:
the greatest risk to this client is injury
A student says "Before taking a test, I feel very alert and a little restless." The nurse can correctly assess the student's experience as:
1. culturally influenced
2. displacement
3. trait anxiety
4. mild anxiety
mild anxiety
A client with an abdominal mass is scheduled for a biopsy. The client has difficulty understanding and asks, "What do you mean? Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient's level of anxiety?:
1. mild
2. moderate
3. severe
4. panic
moderate
For a client experiencing panic, which nursing intervention should be implemented first?:
1. teach relaxation techniques
2. administer a PRN medication
3. prepare to implement physical controls
4. provide calm, brief, directive communication
provide calm, brief, directive communication
A client experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be:
1. "What would you like me to do to help you?"
2. "Why are you are feelings anxious?"
3. "I'm not sure I understand. Give me an example."
4. "You must get your feelings under control before we can continue."
"I'm not sure I understand. Give me an example."
A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder?:
1. "I check where my car keys are eight times."
2. "My legs often feel weak and spastic."
3. "I'm embarrassed to go out in public."
4. "I keep reliving a car accident."
"I check where my car keys are eight times."
A soldier served in combat zones in Iraq. When is it most important for the nurse to screen for signs and symptoms of PTSD?:
1. immediately upon return to US
2. before departing Iraq to return to US
3. one year after returning from Iraq
4. screening should be ongoing
screening should be ongoing
Which assessment finding best supports dissociative fugue? The client states:
1. "I cannot recall why I'm living in this town."
2. "I feel as if I'm living in a fuzzy dream state."
3. "I feel like parts of my body are at war."
4. "I feel very anxious and worried about my problems."
"I cannot recall why I'm living in this town."
The nurse who is counseling a client with dissociative identity disorder should understand that the assessment of highest priority is:
1.
risk for self-harm
2. cognitive function
3. memory impairment
4. condition of self esteem
risk for self-harm
Two nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The manager had a headache the day I was interviewed." Which defense mechanism is evident?:
1. introjection
2. conversion
3. projection
4. splitting
splitting
What type of patient would you see in a hospital setting - mania or hypomania?
mania
What types of food do you give someone with mania?
finger foods
A client with bipolar is dancing nonstop and says "Do you like my moves? I got the grooves, and I'm not a bit tired" how should the nurse document client's mood?:
1. euphoric
2. irritable
3. suspicious
4. confident
euphoric
A person was online for over 24 hours, posting tweets and asking politicians to join Twitter. What features of mania are evident?:
1. increased muscle tension
2. vegetative signs
3. poor judgment
4. cognitive deficits
poor judgment
A client with bipolar becomes hyperactive and threatens to hit another client. What is the nurse's best response?:
1. "Stop that - no one did anything to provoke you"
2. "If you do that one more time, I will seclude you."
3. "Do not hit anyone - we can help you."
4. "Why do you continue with this behavior?"
"Do not hit anyone - we can help you."
Your client has been started on Lithium. What are some side effects that you should be most concerned with?:
1. nausea
2. weight gain
3. thirst
4. blurred vision
blurred vision
Your client with bipolar had a medication added to his regimen. Which of the following atypicals would you expect to see?:
1. Zoloft
2. Tegretol
3. Latuda
4. Parnate
Latuda
Your client with a history of depression, hopelessness and helplessness is admitted to inpatient psych. What is your priority intervention?:
1. orient client to unit and daily schedule
2. call pastoral care
3. request client to sign no self-harm contract
4. introduce him to his roommate
request client to sign no self-harm contract
A client with depression says, "No one cares about me. I'm worthless." Today the client is wearing a new shirt. Which remark by the nurse supports building a positive self-esteem?:
1. "You look nice today."
2. "You're wearing a new shirt."
3. "I like your shirt."
4. "You must be feeling better today."
ANSWER:
"You're wearing a new shirt."
RATIONALE:
-a 'I notice' statements
-makes the client build positive self-esteem as you have noticed that they have done
something for themselves
A nurse working with a client with depression may be at risk for:
1. guilt and despair
2. over-involvement
3. interest and pleasure
4. ineffectiveness and frustration
ANSWER:
ineffectiveness and frustration
RATIONALE:
progress may be very slow with a client and might make the nurse feel as if he/she isn't making any progress
Priority interventions for a client with depression should include:
1. distracting the client from self-absorption
2. careful unobtrusive observation at all times
3. allowing the client to spend long period alone
4. opportunities to assume a leadership role in the milieu
careful unobtrusive observation at all times
Which tool would you likely use for an elderly client to assess for depression?:
1. zung
2. ham-d
3. GDS
4. CAGE
ANSWER:
GAD
RATIONALE:
GAD = geriatic depression scale
Your client has been started on an SSRI. Which medication is he most likely on?:
1. Haldol
2. Zoloft
3. Lithium
4. Cymbalta
ANSWER:
Zoloft
RATIONALE:
the others are not SSRIs
Your client on Parnate (Tranylcypromine) needs to avoid special foods and meds. Which diet would be best for him?:
1. mac and cheese, hot dogs, banana
2. mashed potatoes, ground beef
3. avocado and ham salad
4. cheese noodles and smoked sausage
mashed potatoes, ground beef
Your client is scheduled for ECT in the morning. What is a priority intervention?:
1. have family watch ECT video
2. restrain
client at bedtime to maintain NPO
3. ensure medical workup has been completed
4. educate client that ECT has no side effects
ensure medical workup has been completed
Your client is scheduled for Transcranial Magnetic Stimulation (TMS). He asks you if this is a valid treatment. What is your most therapeutic response?:
1. "Don't ask me, ask your doctor."
2. "It is more invasive than ECT."
3.
"There is some evidence that TMS is helpful for depression."
4. "How do you feel about getting TMS?"
"There is some evidence that TMS is helpful for depression."
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Verified answer
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