Evolve- Psychobiological Disorders

A client with the diagnosis of manic episode of bipolar disorder attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment?

Walking around the facility with a nurse -Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely.

An individual whose employment has been terminated because his company has been acquired by another company is brought by a family member to the mental health clinic because of extreme depression. While talking with the nurse the client says, "I’m a useless, worthless person. No wonder I lost my job." What type of delusion does the nurse identify?

Self-deprecation -The client’s statement is self-derogatory and reflects a low self-appraisal.

A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions?

Unconscious control of unacceptable feelings

An older client is transferred to a nursing home from a hospital with a diagnosis of dementia. One morning, after being in the nursing home for several days, the client is going to join a group of residents in recreational therapy. The nurse sees that the client has laid out several outfits on the bed but is still wearing nightclothes. What should the nurse do?

Help the client select appropriate attire and offer to help the client get dressed

A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client?

Helping the client learn to trust the staff through selected experiences

A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I’m drinking than when I’m sober." What defense mechanism does the nurse identify?

Rationalization -The attempt to justify a behavior by giving it acceptable motives is an example of rationalization

What are the "four A’s" for which nurses should evaluate clients with suspected Alzheimer disease?

Amnesia, apraxia, agnosia, aphasia -Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia); temporoparietal deterioration causes cognitive deficiencies in speech (aphasia), purposeful movements (apraxia), and comprehension of visual, auditory, and other sensations (agnosia).

A client with a borderline personality disorder receives the wrong meal tray for lunch and angrily states, "The next time I see the dietitian, I’m going to throw this tray at her!" What is the most appropriate response by the nurse?

Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietitian is unacceptable behavior

While watching television in the dayroom a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse?

Walking to the end of the hallway where the client is standing -Walking to the end of the hallway where the client is standing lets the client know that the nurse is available. It also demonstrates an acceptance of the client.

An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask the client to do to determine orientation to place?

Identify the name of the clinic’s town

A depressed older client has not been eating well since her admission to the hospital. The client repeatedly states, "No one cares." What is the most appropriate response by the nurse?

"I care about you. What are some foods you especially like?" -The statement "I care about you. What are some foods you especially like?" is a direct response to the client’s concern and permits some exploration of food choices

What is essential for the nurse to do when approaching a client during a period of overactivity?

Using a firm but caring and consistent approach

A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing:

Thiamine deficiency -The deficiency of thiamine (vitamin B1) is thought to be a primary cause of alcohol-induced amnestic disorder.

A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? (Select all that apply.)

2 Verbalizes difficulty identifying personal strengths 4 Acknowledges the effects of the addiction on the family 5 Addresses how the addiction has contributed to family distress

A client with the diagnosis of bipolar disorder, depressive episode, has been hospitalized on a psychiatric unit for 1 week. What is the most appropriate activity for this client?

Talking with the nurse several times during the day -Involving the client in a one-on-one conversation provides individualized, low-anxiety-producing attention and gives the message that the client is important, which supports self-esteem.

The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child’s behavior. What is best response by the nurse?

"It must be frustrating to deal with your child’s behavior." -Stating that it must be frustrating acknowledges the parent’s distress and encourages verbalization of feelings.

An adolescent who has had the diagnosis of conduct disorder since the age of 9 is placed in a residential facility. The adolescent has a history of fighting, stealing, vandalizing property, and running away from home. The adolescent is aggressive, has no friends, and has been suspended from school repeatedly. What is the nurse’s priority when planning care?

Preventing violence

What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program?

Alcoholism involves the entire family. -Research indicates that alcoholism is a family disease, with its roots in the family of origin

A recovering alcoholic joins Alcoholics Anonymous (AA) to help maintain sobriety. What type of group is AA?

Self-help group

A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. The nurse remembers that the main reason that clients use self-mutilation is to:

Express anger or frustration -Typically, recurrent self-mutilation is an expression of intense anger, helplessness, or guilt or is a form of self-punishment.

A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client’s compulsive ritual involves changing her clothing 8 to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of:

Dependence versus independence

An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I’m not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using?

Projection -The client is assigning to others those feelings and emotions that are unacceptable to him- or herself. Introjection is treating something outside the self as if it is inside the self.

A depressed client has been sitting alone in a chair most of the day and displays no interest in eating. How should the nurse plan to meet this client’s nutritional needs?

Stay with the client during meals -Active support is demonstrated when the nurse sits with the client during meals.

The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem?

Disruptions in cerebral blood flow, resulting in thrombi or emboli -Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area.

The nurse is caring for a client with Alzheimer’s disease who exhibits behaviors associated with hyperorality. To meet the client’s need for a safe milieu, the nurse will instruct staff to monitor the client:

For attempts at eating inedible objects -Hyperorality is the compulsive need to taste and chew inedible objects.

In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies’ restroom of a restaurant. During admission the client shouts, "Don’t come near me! My stomach is filled with bombs, and I’ll blow up this place if anyone comes near me." The nurse concludes that the client is exhibiting:

Delusional thinking

What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation?

Electroconvulsive therapy

A nurse uses behavior modification to foster toilet-training efforts in a cognitively impaired child. What reward should the nurse provide to reinforce appropriate use of the toilet?

Hug with praise -Secondary reinforcers involve social approval; a hug meets this requirement.

A nurse is caring for several clients who are going through withdrawal from alcohol. The primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they:

Are dependent on it

What should a nurse conclude that a client is doing when he makes up stories to fill in blank spaces of memory?

Confabulating

A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing?

Guilt

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client?

Constant one-to-one supervision

An older adult who lives alone tells a nurse at the community health center, "I really don’t need anyone to talk to. The TV is my best friend." The nurse identifies the defense mechanism known as:

Denial

A 54-year-old client has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After being found walking down a street, disoriented and semi-naked, the client is admitted to the hospital, and a diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety. What is the best approach for the nurse to take?

Reassuring the client with the frequent presence of staff -The client needs constant reassurance because forgetfulness blocks previous explanations; frequent presence of staff serves as a continual reminder.

A client describes his delusions in minute detail to the nurse. How should the nurse respond?

By changing the topic to reality-based events

A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence?

Blurs reality -The addict tries to avoid stress and reality. The drug produces a blurring of these feelings to the point that the addict becomes dependent on it. The psychological effect is usually more important than the ability to ease pain. Large doses of opioids, not cocaine, can cause a dreamlike state. Cocaine can increase, not decrease, motor activity.

For which clinical indication should a nurse observe a child in whom autism is suspected?

Lack of eye contact -Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism.

A nurse concludes that a client’s withdrawn behavior may temporarily provide a:

Defense against anxiety -Withdrawal provides a temporary defense against anxiety because it limits contact with reality and reduces the client’s world.

A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic antidepressant. The client asks the nurse what the medication will do. What is the best response by the nurse?

"The medication will increase your appetite and make you feel better." -Tricyclic antidepressants create a general sense of well-being, increase appetite, and help lift depression.

What is the most appropriate nursing intervention when a client is seen openly masturbating in the recreation room?

Escorting the client from the room -Escorting the client from the room accepts the client but rejects the behavior. The nurse should set limits on this behavior when it is not performed in a private area

An autistic toddler is sitting in a corner, rocking and spinning a top. How can the nurse be most therapeutic when approaching this toddler?

Sitting with the toddler while watching the spinning top to provide a nonintrusive presence -Autistic children relate best with objects, which can be used as a bridge in interpersonal relationships; this begins at the child’s level. Autistic children often become agitated when movement is restricted and personal space is invaded. Autistic children usually have difficulty tolerating being touched. They will not initiate contact or interactions.

What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa?

Based on realistic limits -Realistic guidelines reduce anxiety, increase feelings of security, and increase adherence to the therapeutic regimen.

A 12-year-old child who has a history of school failure and destructive acting out is admitted to a child psychiatric unit with the diagnosis of conduct disorder. The youngest of three children, the child is identified by both the parents and the siblings as the family problem. The nurse recognizes the family’s pattern of relating to the child as:

Scapegoating -When all members of a family blame one member for all their problems, scapegoating is occurring. There are no data to indicate a controlling, patronizing, or overburdening pattern of relating.

A client with a diagnosis of major depression refuses to participate in unit activities, saying that she is "just too tired." What is the best nursing approach?

Accepting the client’s feelings about activities calmly while setting firm limits

A client tells the nurse, "The voices say I’ll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse?

"I understand that these voices are real to you, but I want you to know that I don’t hear them." -The statement "I understand that these voices are real to you, but I want you to know that I don’t hear them" demonstrates recognition and acceptance of the client’s feelings; it also points out reality

A client on the psychiatric unit tells the nurse, "The voices have told me that I’m in danger. They say I’ll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse to this statement?

"I know that these voices are real to you, but I want you to know that I don’t hear them."

At times a client’s anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let’s see whether we mean the same thing." What communication technique is being used by the nurse?

Seeking consensual validation -Seeking consensual validation is a technique that prevents misunderstanding so that both the client and the nurse can work toward a common goal in the therapeutic relationship.

A client who is on the third day of detoxification therapy becomes agitated and restless. What are the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that apply.)
1
Polydipsia
2
Drowsiness
3
Diaphoresis
4
Tachycardia
5
Hypertension

3 Diaphoresis 4 Tachycardia 5 Hypertension -As withdrawal from alcohol progresses, autonomic hyperactivity occurs, resulting in profuse diaphoresis, a heart rate faster than 100 beats/min, and increases in temperature, respiratory rate, and blood pressure. Polydipsia, excessive intake of oral fluids, is one of the signs of diabetes mellitus. Hyperalertness, not drowsiness, may occur.

A mother of a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD) tells the nurse that when she is reading storybooks to her son, about halfway through the story he becomes distracted, fidgets, and stops paying attention. The nurse suggests that the mother:

Shorten the rest of the story -Shortening the story nonjudgmentally limits the activity while supporting the child’s self-esteem; the child with ADHD cannot control his inattention and hyperactivity. The mother should select activities that are more interactive or interesting for the child to engage his attention.

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. The nurse knows that the defense mechanism being utilized by this woman is:

Repression

A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? (Select all that apply.)

1 Calm 2 Matter-of-fact

A client with a generalized anxiety disorder is hospitalized. The nurse determines that an environment conducive to reducing emotional stress and providing psychological safety for this client is one in which:

Realistic limits and controls are set -Setting realistic limits and controls makes the environment as emotionally nonthreatening as is realistically possible. All needs cannot be met; the person must learn how to cope with delaying gratification. It is not possible or realistic to meet all of a person’s requests. Order in the environment is of less importance; providing a nonthreatening environment is the priority action.

What client response should the nurse anticipate when an attempt is made to prevent a client from carrying out ritualistic behavior?

Anger

The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse?

"I didn’t hear anyone talking; come with me to your room." -The nurse is focusing on reality and trying to distract and refocus the client’s attention.

A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which action is most appropriate for the nurse to implement?

Assuring the client that the symptoms are part of the withdrawal syndrome

An adolescent is admitted to the psychiatric service in stable physical condition with the diagnosis of anorexia nervosa. The adolescent has lost 20 lb in 6 weeks and is very thin but is excessively concerned about being overweight. What is the most important initial nursing intervention?

Attempting to establish a trusting relationship with the adolescent -the problem is psychological. Therefore the nurse’s initial approach should be directed toward establishing trust.

A client is admitted to the mental health unit after attempting suicide. When a nurse approaches, the client is tearful and silent. What is the best initial nursing intervention?

Saying, "I see that you’re crying. Tell me what’s going on in your life, and we can work on helping you."

A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified (autistic disorder). What should the nurse consider most unusual for the child to demonstrate?

Responsiveness to the parents -One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.

A nurse is teaching the parents of a school-aged child with attention deficit-hyperactivity disorder (ADHD) about the prescribed medication methylphenidate (Ritalin). When should the daily dose be administered?

Just after breakfast -Methylphenidate (Ritalin) should be given just after breakfast to avoid appetite suppression. Giving the medication when the child arrives at school or immediately before lunch would not allow enough time for the medication to be effective during school hours. Giving the medication when the child arrives home from school would not allow the medication to be effective during school hours, and would likely interfere with the child’s sleep times.

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower?

"I’ll help you take your shower now." -The client is displaying a self-care deficit; stating the intention of helping the client shower is direct, does not require the client to make a decision, provides help, and meets the client’s physiological and psychological needs. The client may or may not be capable of making a decision; if the client says no, the nurse will be confronted with a dilemma:

A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client’s use of confabulation?

Marked loss of memory -Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered.

A client believes that doorknobs are contaminated and refuses to touch them except with a paper tissue. What nursing intervention will be most therapeutic for this client?

Supplying the client with tissues to maintain function until the anxiety eases -The client is using this compulsive behavior to control anxiety and needs to continue with it until the anxiety is reduced and more acceptable methods are developed to handle it.

A nurse stops by the room of a newly admitted depressed client and offers to walk with the tearful client to the evening meal. The client looks intently at the nurse but says nothing. What is the best response by the nurse?

"It must be very difficult for you to be on a psychiatric unit."

A male client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention?

Presenting a united, consistent staff approach

A 6-year-old child who has autism exhibits frequent spinning and hand-flapping behaviors. What should the nurse teach the parents to do to limit these actions?

Use another activity to distract the child

A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client?

Having a staff member sit with the client in a quiet area during mealtimes -By sitting with the client during mealtimes the nurse can evaluate how much the client is eating; this encourages the client to eat and begins the construction of a trusting relationship. Fewer distractions may help the client focus on eating.

What characteristic uniquely associated with psychophysiological disorders differentiates them from somatoform disorders?

Underlying pathophysiology -The psychophysiological response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatoform disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances.

A delirious client sees a design on the wallpaper and perceives it as an animal. How should a nurse communicate what the client perceived in the change-of-shift report?

An illusion -An illusion is a misperception or misinterpretation of an actual external stimulus. A delusion is a false belief that cannot be changed even by evidence; it is associated with psychosis. A hallucination results from an imaginary, not real, stimulus. An idea of reference is a belief that others are talking about the person. Topics

Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization?

Project involving drawing -An art-type project that may be worked on successfully at one’s own pace is appropriate for a depressed client. Board games and card games with three other clients require too much concentration and may increase the client’s feelings of despair.

A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feeling stop." What clinical manifestation is evident?

Feelings of panic -The client can no longer control or tolerate these overwhelming feelings and is seeking help.

An anxious client reports experiencing pain in the abdomen and feeling empty and hollow. A diagnostic workup reveals no physical causes of these clinical findings. What term best reflects what the client is experiencing?

Somatization

What should nurses consider when working with depressed young children?

It is important to include the family in the treatment plan.

How can a nurse minimize agitation in a disturbed client?

By limiting unnecessary interactions with the client -Limiting unnecessary interactions will decrease stimulation and therefore agitation

A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don’t deserve a comfortable bed; give it to someone else." The best response response by the nurse is:

"Everyone has a bed. This one is yours." -A matter-of-fact approach helps avoid a cycle in which the nurse expresses concern to a client who feels unworthy, which increases feelings of unworthiness

An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention?

Giving the client one simple direction at a time in a firm low-pitched voice -Clients who are out of control are seeking control and frequently respond to simple directions stated in a firm voice.

A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed?

Fluvoxamine (Luvox) -Fluvoxamine (Luvox) blocks the uptake of serotonin, which leads to a decrease in obsessive-compulsive behaviors. Benztropine (Cogentin) is an antiparkinsonian agent, not an antianxiety agent. Amantadine is an antiparkinsonian agent, not an antianxiety agent. Diphenhydramine (Benadryl) is an antihistamine, not an antianxiety agent.

A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? (Select all that apply.)

3 Repetitive activities 4 Self-injurious behaviors 5 Lack of communication with others -Perseveration (repetition of a behavior pattern) is commonly demonstrated by children with autism; this behavior provides comfort. Self-stimulation through injurious behavior is associated with autism. Children with autism have difficulty communicating or do not communicate at all with others. There may be unusual eating habits and food preferences, but lack of appetite is not associated with autism. Mood disorders are usually not associated with autism.

A woman with bipolar disorder, manic episode, has been spending thousands of dollars on clothing and makeup. She has been partying in bars every night and rarely sleeps or eats. The nurse in the outpatient clinic, knowing that this client rarely eats, recognizes that her eating problems most likely result from her:

Excessive physical activity -During a manic episode hyperactivity and the inability to sit still long enough to eat are the causes of eating difficulties. Feelings of guilt do not precipitate eating difficulties in clients with the diagnosis of bipolar disorder, manic episode.

A nurse is evaluating a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident?

2 years By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound.

When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response?

Saying, "I’ll be back in a few minutes so we can talk." -Saying, "I’ll be back in a few minutes so we can talk," allows the angry client time to regain self-control; announcing a plan to return will ease fears of abandonment or retribution.

A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients?

Impulsive -Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder.

A client with a diagnosis of bipolar disorder, manic episode, is admitted to the mental health unit. Because the environment is important, what should the nurse do?

Place the client in a private room to provide a quiet atmosphere

What should a nurse consider when planning care for a client who is using ritualistic behavior?

Clients do not want to repeat their rituals but feel compelled to do so.

A nurse, planning care for a client who is an alcoholic, knows that the most serious life-threatening effects of alcohol withdrawal usually begin after a specific time interval. How many hours after the last drink do they occur?

24 to 72 -Alcohol withdrawal delirium, a life-threatening central nervous system response to alcohol withdrawal, occurs in 1 to 3 days when the blood alcohol levels drops as alcohol is detoxified and excreted. Jitteriness, nervousness, and insomnia may occur 8 to 12 hours after withdrawal; these are not life-threatening issues. Nervousness, insomnia, nausea, vomiting, and increased blood pressure and pulse may occur after 12 to 24 hours; these are not life-threatening problems. Withdrawal symptoms will have begun to subside after 72 to 96 hours, and the risk for complications is diminished.

A nurse is caring for an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?

Loosened associations and hallucinations

A middle-age female client who has lost 20 lb over the last 2 months cries easily, sleeps poorly, and refuses to participate in any family or social activities that she previously enjoyed. What is the most important nursing intervention?

Allowing the client to externalize her feelings, especially anger, in a safe manner

A nurse recalls that language development in the autistic child resembles:

Echolalia -The autistic child repeats sounds or words spoken by others

An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I’m tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing?

Moderate

One morning a client with the diagnosis of acute depression says to the nurse, "God is punishing me for my past sins." What is the best response by the nurse?

"You really seem to be upset about this."

A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism?

Active membership in Alcoholics Anonymous

One day the nurse and a young adult client sit together and draw. The client draws a face with horns and says, "This is me. I’m a devil." What is the best response by the nurse?

"When I look at you I see a person, not a devil."

What is the best nursing intervention when the language of a client in the manic phase of a bipolar disorder becomes vulgar and profane?

Recognizing that the behavior is part of the illness but setting limits on it

A hyperactive 9-year-old child with a history of attention deficit-hyperactivity disorder is admitted for observation after a motor vehicle collision. On what should nursing actions be focused when the nurse is teaching about personal safety?

Talking with the child about the importance of using a seat belt

What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants?

Seizure activity -Stimulants increase the excitatory neurotransmitters (e.g., adrenaline and dopamine), lowering the seizure threshold.

A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I’m no good." What is the most appropriate response by the nurse?

"You must have been upset to try to take your life."

A client with alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse’s initial reply?

"No, I don’t see any bugs."

A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual?

Denying this activity may precipitate an increased level of anxiety.

One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client begs, "Please let me go. I trust you. The Mafia is going to kill me tonight." Which response is most therapeutic?

"You’re frightened. Come with me to your room, and we can talk about it."

A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate?

Confusion immediately after the treatment

A child has been hospitalized repeatedly for illnesses of unknown origin. Finally the health care provider makes the diagnosis of Munchausen syndrome by proxy. What is the most therapeutic approach by the nurse to the involved parent?

Open communication

Hospitalization or day-treatment centers are often indicated for the treatment of a client with obsessive-compulsive disorder because these settings:

Provide the neutral environment the client needs to work through conflicts

A client in the mental health clinic has a phobia about closed spaces. Which desensitization method should the nurse expect to be used successfully with this client?

Imagery

A client who is a polysubstance abuser is mandated to seek drug and alcohol counseling. What is an appropriate initial outcome criterion for this client?

Verbalizes that a substance abuse problem exists

A client has been hospitalized for 3 weeks while receiving a tricyclic medication for severe depression. One day the client says to the nurse, "I’m really feeling better; my energy level is up." After the encounter an aide tells the nurse that the client has given away his favorite jacket. What should the nurse conclude that the client’s statement indicates?

Increased risk for suicide

A client who is hallucinating actively approaches the nurse and reports, "I’m hearing voices that are saying bad things about me." What should the nurse do?

Reply, "I’ll stay with you for a while because you seem frightened."

When talking with one of the day nurses, a client with the diagnosis of anorexia nervosa states that the day nurses give better care and are nicer than the night nurses. The client also asks a question that the day nurse knows was already answered by one of the night nurses. What conclusion should the nurse make about the client?

The client is trying to divide the staff, and the behavior should be reported to the other staff members

A client is responding within an hour of receiving naloxone to combat respiratory depression from an overdose of heroin. Why should a nurse continue to closely monitor this client’s status?

Symptoms of the heroin overdose may return after the naloxone is metabolized.

A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The statement that best describes how clients with obsessive-compulsive behavior view this disorder is:

"I know there’s no reason to do these things, but I can’t help myself."

What should the nurse do to achieve a primary objective of providing a therapeutic daycare environment for a client who is withdrawn and reclusive?

Foster a trusting relationship

A nurse uses the CAGE screening test for alcoholism to determine an individual’s potential for a drinking problem. What is one of the four questions included on this test?

"Have you ever felt bad or guilty about your drinking?" -The CAGE screening test for alcoholism contains four questions, corresponding to the letters CAGE: Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (as an "Eye-opener") to steady your nerves or get rid of a hangover? "How often did you have a drink containing alcohol in the past year?" is one of the 10 questions on the Alcohol Use Disorders Identification Test (AUDIT). "Do you feel that you are a normal drinker" and "Are you always able to stop drinking when you want to" are two of the 26 questions on the Michigan Alcohol Screening Test (MAST).

What is a therapeutic nursing action in the care of a depressed client?

Sitting down next to the client at frequent intervals

A widow who is hospitalized for a medical problem has dementia of the Alzheimer type and is no longer able to live alone. The client is to be transferred from the hospital to a long-term care facility. When should the staff begin preparation for the transfer?

Immediately after the client’s admission to the hospital

An adult client confides to a clinic nurse, "I fantasize about having sex with children, and I get the urge to do it, too." What is the most appropriate response by the nurse?

Asking the client, "Have you ever acted on these thoughts?"

A nurse is caring for a preschool-aged child with a history of physical and sexual abuse. What type of therapy will be the most advantageous for this child?

Play

A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do?

Redirect the conversation with the nurse to physical symptoms

When reviewing the medications for a group of clients on a psychiatric unit, the nurse concludes that the pharmacotherapy for anxiety disorders is moving away from benzodiazepines and moving toward:

Selective serotonin reuptake inhibitors -Selective serotonin reuptake inhibitors have better safety profiles and do not carry the risk of substance abuse and tolerance. Anticholinergics are administered concurrently with antipsychotics to minimize extrapyramidal side effects. Lithium carbonate is a drug used to treat bipolar disorder. Antipsychotics are administered to clients with thought disorders.

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider that clients with OCD:

Do not want to repeat the ritual but feel compelled to do so

A 6-year-old child with autism is nonverbal and makes limited eye contact. What should the nurse do initially to promote social interaction?

Engage in parallel play while sitting next to the child

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating?

Is too busy to take the time to eat

A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client’s primary problem?

Low self-esteem

What is the best nursing intervention during the working phase of the therapeutic relationship with which to meet the needs of individuals who demonstrate obsessive-compulsive behavior?

Supporting rituals while setting realistic limits

A nurse concludes that a client has successfully achieved the long-term goal of mobilizing effective coping responses when the client states that when he feels himself getting anxious he will:

Perform a relaxation exercise

What should the nurse identify as the foremost basis for the development of schizophrenia?

Biological perspective -The biological factors, including genetics, neuroanatomy, and abnormal neurotransmitter-endocrine interactions, prevail as the origin of schizophrenia as a result of studies conducted during the twentieth century.

When caring for clients who are demonstrating manic behavior, the nurse must constantly reevaluate these clients’ physical needs. What characteristic about these clients makes this particularly important?

May become exhausted from excessive activity

A nurse in a community therapeutic recreation program is working with a client with dysthymia. The treatment plan suggests group activities when possible for this client. What is the priority rationale for this intervention?

A group can offer increased support.

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation?

Leaving a dim light on in the client’s room at night

Sildenafil (Viagra) is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug. (Select all that apply.)

1. Flushing 2. Headache 3. Dyspepsia – Flushing is a common central nervous system response to sildenafil (Viagra). Headache is a common central nervous system response to sildenafil. Dyspepsia is a common gastrointestinal response to sildenafil. Diarrhea, not constipation, is a common gastrointestinal response to sildenafil. Hypotension, not hypertension, is a cardiovascular response to sildenafil. It should not be taken with antihypertensives and nitrates, because drug interactions can precipitate cardiovascular collapse.

When a nurse sits next to a depressed client and begins to talk, the client responds, "I’m stupid and useless. Talk with the other people who are more important." Which response is most therapeutic?

"I want to talk with you because you are important to me." -The response "I want to talk with you because you are important to me" is an expression of the nurse’s positive thoughts about the client and lets the client know that the nurse is concerned.

One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." The nurse identifies that this as an example of:

Depersonalization =The state in which the client feels unreal or believes that parts of the body are distorted is known as depersonalization or loss of personal identity.

A nurse begins a therapeutic relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action?

Respecting the client’s need for social isolation

A college student visits the health center and describes anxiety about having to declare an academic major. What developmental conflict, according to Erikson, is this client still attempting to resolve?

Identity versus role confusion -The client is demonstrating a search for self and has not resolved the developmental conflict of adolescence, identity versus role confusion.

What is the best nursing intervention to encourage a socially withdrawn client to talk?

Focusing on nonthreatening subjects -Nursing care involves a steady attempt to draw the client into some response. This can best be accomplished by focusing on nonthreatening subjects that do not demand a specific response

A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity?

Invite another client to take part in a joint activity with the nurse and the client

Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?

Suspicious feelings

An agitated, acting-out, delusional client is receiving large doses of haloperidol (Haldol), and the nurse is concerned because this drug can produce untoward side effects. Which clinical manifestations should alert the nurse to stop the drug immediately? (Select all that apply.)

1. Jaundice 3. Tachycardia -Jaundice signifies liver function interference and requires that the medication be stopped. Tachycardia, QT-interval prolongation, and cardiac arrest are life-threatening cardiovascular effects of haloperidol (Haldol).

A client with schizophrenia reports having ongoing auditory hallucinations that he describes as "voices telling me that I’m a bad person" to the nurse. What is the best response by the nurse?

"Try to ignore the voices." -Clients can sometimes learn to push auditory hallucinations aside, particularly within the framework of a trusting relationship; it may provide the client with a sense of power to manage the voices.

A delusional client is actively hallucinating and worried about being stalked by a terrorist group. What defense mechanism does the nurse identify as the most prominent in this situation?

Projection

A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? (Select all that apply.)

1 Tremors 2 Anorexia -Hand tremors, related to dysfunction of the nervous system, are an early sign of withdrawal from alcohol; alcohol depresses the central nervous system, interferes with nerve conduction, and results in peripheral neuropathy. Signs and symptoms of alcohol withdrawal begin within 12 hours of cessation or decrease in alcohol consumption, peak in 48 to 72 hours, and usually begin to ease after 4 or 5 days. Anorexia, nausea, and vomiting are early signs of withdrawal from alcohol; alcohol affects the gastrointestinal system and can cause gastritis, pancreatitis, hepatitis, and cirrhosis. Psychomotor agitation is a late, not an early, sign of alcohol withdrawal. Transient visual, auditory, and tactile hallucinations, rather than delusions, are associated with alcohol withdrawal. Confusion, disorientation, and impaired cognition are not early signs of alcohol withdrawal; alcohol withdrawal delirium occurs in less than 10% of those who experience the alcohol withdrawal syndrome.

What should a nurse do when caring for a client whose behavior is characterized by pathological suspicion?

Help the client feel accepted by the staff on the unit

A client in the early dementia stage of Alzheimer’s disease is admitted to a long-term care facility. Which activities must the nurse initiate? (Select all that apply.)

1 Weighing the client once a week 2 Having specialized rehabilitation equipment available 3 Establishing a schedule with periods of rest after activities

A 25-year-old woman is seeking outpatient counseling after thinking about suicide. The nurse realizes that there some factors place individuals at a higher risk for suicide. Which of these factors increases the risk for suicide? (Select all that apply.)

1 Impulsivity 2 Panic attacks 3 Unemployment 4 Substance abuse -Impulsivity, panic attacks, unemployment, and substance abuse have all been linked with an increased risk for suicide. A sense of responsibility to family and religious beliefs are considered protective factors that may lessen the risk of suicide.

A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client’s ability to meet personal needs without manipulating others? (Select all that apply.)

2 Provide physical outlets for aggressive feelings 3 Establish a contract regarding manipulative behavior 4 Develop activities that provide opportunities for success

A client is brought to the emergency department by friends because of increasingly bizarre behavior. Which signs does the nurse identify that indicate that the client was using cocaine? (Select all that apply.)

1 Euphoria 2 Agitation 5 Hypervigilance 6 Impaired Judgement

What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa?

Set limits The client’s security is increased by the setting of limits; guidelines remove responsibility for behavior from the client and increase compliance with the regimen.

A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client’s energy is returning and the client no longer talks about suicide. What should the nurse do in response to this client’s behavior?

Keep the client under closer observation – As the client’s motivation and energy return, the likelihood that suicidal ideation will be acted out increases.

A disturbed male client, unprovoked, attacks another client. A short-term initial plan for this client should include:

Having the client sit with a staff member in whom he trusts -The client needs someone with whom he has a working and trusting relationship; this individual must observe, protect, anticipate, and prevent the client from acting out destructive impulses.

Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat:

Clinical depression -ECT is used to treat clinical depression in clients who do not respond well to a trial of psychotropic medications or are so severely depressed that immediate intervention is needed.

The nurse determines that the therapy that has the highest success rate for people with phobias is:

Desensitization involving relaxation techniques -The most successful therapy for people with phobias consists of behavior modification techniques involving desensitization.

A confused hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse?

"It can be frightening to feel that way."

A client is admitted to a mental health facility for depression. What action should a nurse take to help the client develop a positive self-regard?

Involve the client in activities that promote success

A nurse is caring for a client who has been experiencing delusions. According to psychodynamic theory, delusions are:

A defense against anxiety

A client has been receiving oxycodone (OxyContin) for moderate pain associated with multiple injuries sustained in a motor vehicle collision. The client has returned three times for refills of the prescription. What behavior, in addition to the client’s slurred speech, leads the nurse to suspect opioid intoxication?

Constricted pupils -Pupil constriction is a physical response to opioid intoxication; the pupils will dilate with opioid overdose. Opioids cause apathy or a depressed, sad mood (dysphoria); lability of mood is associated with the use of anabolic-androgenic steroids. Opioids cause drowsiness and psychomotor retardation; alertness is associated with the use of stimulants such as caffeine and amphetamines. Opioids depress the respiratory center of the brain, causing slow, shallow respirations; increases in temperature, pulse, respirations, and blood pressure are associated with cocaine use.

A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down to talk. The client requesting the nurse’s attention is manipulative and uses acting-out behaviors when demands go unmet. How should the nurse intervene?

By saying to the interrupting client, "I’ll be back to talk with you after I orient this new client."

A client with schizophrenia says to the nurse, "I’ve been here 5 days. There are 5 players on a basketball team. I like to play the piano." How should the nurse document this cognitive disorder?

Loose association

An adult is found to have schizotypal personality disorder. How should a nurse describe the client’s behavior?

Introverted and emotionally withdrawn -These clients usually display social inadequacy and lack of emotional contact with others. Rigid and controlling behaviors reflect an obsessive-compulsive personality disorder. Submissive and immature behaviors reflect a dependent personality disorder. Arrogant and attention-seeking behaviors probably reflect a narcissistic personality disorder.

The nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care?

Exhibits lack of empathy for others -Self-motivation and self-satisfaction are of paramount concern to people with antisocial personality disorder, and they have little or no concern for others.

A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. What is the most appropriate conclusion to make about what the client was experiencing?

Illusion

A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?

Intramuscular injections of thiamine -Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs. A traditional phenothiazine is a neuroleptic antipsychotic that should not be prescribed because it is hepatotoxic. Antipsychotics are avoided; the use of these has a higher risk for toxic side effects in older or debilitated persons. Chlorpromazine, a neuroleptic, will not be used because it is severely toxic to the liver.

A nurse is caring for a child with autism. Which intervention is most appropriate in an attempt to promote socialization for this child?

Imitating and participating in the child’s activities

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of:

Grandeur

A constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome is:

Role experimentations -Adolescents learn about who they are by assuming and experiencing a variety of roles; experimentation results in the retention or rejection of behavior and roles.

The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client’s spouse to do?

Prefill a weekly drug box with the medications for the spouse to self-administer -Clients with early dementia of the Alzheimer type usually have some short-term memory loss. A prefilled box of medications eliminates the need to determine what drugs need to be taken. Also, it provides the spouse with objective proof that the medications have or have not been taken.

The nurse notes that a client has been experiencing a somatic delusion. Which statement led to this conclusion?

"My stomach has disintegrated."

People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? (Select all that apply.)

2 Denial 4 Confusion 5 Helplessness -Rationale: Shock and disbelief are the initial responses to a traumatic experience; a situational crisis usually is unexpected, and its impact causes disequilibrium. Disequilibrium results in confusion, disorganization, and difficulty making decisions. When a person is unable to cope, helplessness and regression often emerge; a crisis occurs when there is a painful, frightening event that is so overwhelming an individual’s usual coping mechanisms are inadequate.

On the third day of hospitalization, a client with a history of heavy drinking begins experiencing alcohol withdrawal delirium. What is the most appropriate response by the nurse when the client begins experiencing hallucinations?

Administering the prescribed medication to the client to subdue the agitated behavior -The nurse must administer the prescribed medication to the client to subdue the agitated behavior in this life-threatening situation. The client’s central nervous system (CNS) is overstimulated, and seizures and death can occur. CNS-depressant medications, usually benzodiazepines, are needed to blunt the withdrawal effects.

A nurse knows individuals who are alcoholics use alcohol to:

Blunt reality

An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. The nurse identifies that these problems as the result of:

Receptive aphasia -Receptive aphasia interferes with interpreting and defining words in addition to following directions and selecting clothes. Following directions does not require skill in judgment or decision-making.

During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?

Stressors that appear to precipitate the client’s disruptive behavior

Which nursing intervention is most important for a client who has the diagnosis of antisocial personality disorder?

Providing clear boundaries and consequences

A client is admitted with a conversion disorder. What is the primary nursing intervention?

Exploring ways to verbalize feelings -The priority is getting the client to express feelings appropriately rather than through the use of physical symptoms. Focusing on symptoms will encourage their use by the client. An expression of feelings, not an intellectual understanding of the cause of the symptoms, is required.

An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. A specific outcome criterion unique to adolescents with this problem is:

Demonstration of respect for the rights of others -Demonstrating respect for the rights of others is a specific outcome criterion for children with a risk for violence directed at others; children with the diagnosis of conduct disorder typically present with a repetitive and persistent pattern of behavior that violates the basic rights of others or major age-appropriate societal norms or rules

A nurse is caring for an adolescent who has anorexia nervosa. The nutritional treatment of anorexia is composed of several guidelines. Which guidelines should the nurse emphasize? (Select all that apply.)

3 Increasing food intake gradually 4 Limiting mealtime to half an hour 5 Providing privileges for goal achievement

An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is ungroomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. What should the nurse do during the first few hospital days?

Seek out the client frequently to spend short periods of time together

A nurse is caring for an older adult with the diagnosis of dementia. Which manifestations are expected in this client? (Select all that apply.)

1 Resistance to change 2 Inability to recognize familiar objects 4 Inability to concentrate on new activities or interests 5 Tendency to dwell on the past and ignore the present

What characteristic of an environment should the nurse consider important for a confused older adult with socially aggressive behavior?

Sets limits -Having poor control, these individuals cannot set limits for themselves and require an environment in which appropriate limits for behavior are set for them.

A nurse is interacting with a depressed, suicidal client. What themes in the client’s conversation are of most concern to the nurse? (Select all that apply.)

3 Loneliness 4 Hopelessness

During the orientation tour for three new staff members, a young, hyperactive manic client greets them by saying, "Welcome to the funny farm. I’m Jo-Jo, the head yo-yo." Which meaning can the nurse assign to the client’s statement?

Anxious over the arrival of new staff members -The client’s behavior demonstrates increased anxiety. Because it was directed toward the new staff, it was probably precipitated by their arrival.

Clients addicted to alcohol often use the defense mechanism of denial. What is the reason that this defense is so often used?

It reduces their feelings of guilt

Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing?

Delusion -A delusion is a fixed false belief. An illusion is a false sense interpretation of an external stimulus. Confabulation is the client’s attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory perception with no external stimulus.

When a disturbed client who has a history of using neologisms says to the nurse, "My lacket huss kelong mon," the nurse should respond by:

Telling the client that these words cannot be understood

An antidepressant is prescribed for a depressed older client. After 1 week the client’s son expresses concern that there does not seem to be much improvement. How should the nurse respond?

"Antidepressant therapy requires several weeks before it becomes effective."

A client is admitted to the drug detoxification unit for cocaine withdrawal. What is the nurse’s primary concern while working with clients withdrawing from cocaine?

Risk for self-injury -The greatest risk in cocaine withdrawal is risk for self-injury. The risk for seizure is increased while a person is under the influence of cocaine, not during withdrawal. Although dehydration may occur during cocaine use and withdrawal, it is not the priority concern. People in cocaine withdrawal, although irritable, are more apt to hurt themselves than others.

A client in an acute mental health unit appears severely depressed. The client does not initiate conversations or perform personal care. Questions are answered with a barely audible one- or two-word response. The nurse sits with the client and makes no demands. On what premise is the nurse’s intervention for this client based?

Spending time with depressed clients demonstrates that they are worthy of attention. -A severely depressed client has low self-esteem; this intervention demonstrates that the client is important and worthy of attention.

During a special meeting to discuss the unexpected suicide of a recently discharged client, a nurse overhears another client moan softly, "I’m next. Oh my God, I’m next. They couldn’t protect him, and they can’t protect me, either." What is the most therapeutic response by the nurse?

"You seem to be afraid that you’ll hurt yourself."

A 17-year-old client is admitted to the hospital because of weight loss and malnutrition, and the health care provider diagnoses anorexia nervosa. After the client’s physical condition is stabilized, the provider, in conjunction with the client and parents, decides to institute a behavior-modification program. What component of behavior modification verbalized by one of the parents leads the nurse to conclude that the parent has an understanding of the therapy?

Rewarding positive behavior -In behavior modification, positive behavior is reinforced and negative behavior is punished or not reinforced. Deconditioning the client’s fears, decreasing the number of unnecessary restrictions, and reducing the number of anxiety-causing situations may each be a part of the program, but none is a major component.

The parents of an overweight 12-year-old bring their child to the mental health clinic. One parent says, "You’ve got to do something to help us—just look how huge he is." The child tells the nurse, "I hate school. The other kids tease me about my weight. I’m always last when they pick teams in gym." What is the most therapeutic response by the nurse?

"That hurts a lot when you want to be liked."

A male client with the diagnosis of pedophilia is admitted to the psychiatric hospital because of repeated episodes of exhibitionism. In the recreation room the client exposes himself to a nurse and begins to masturbate. How should the nurse respond?

By telling the client that the behavior is unacceptable and to stop -Exposing the genitals and masturbating in a public place are unacceptable behaviors. Unacceptable behavior should be pointed out to the client and the client should be instructed to stop.

A nurse is caring for a client with a bipolar disorder depressive episode. What should the nurse’s objective for this client be?

Feeling comfortable with the nurse -Before therapy can begin, a trusting relationship must be developed. A client with major depression will not have the impetus or energy to investigate new leisure activities. Participating in small group activities is not appropriate initially; the client does not have the physical or emotional energy to interact with a small group of people. Initiating conversations about feelings will not be successful unless the client develops a trusting, comfortable relationship with the nurse.

A client with paranoid schizophrenia tells the nurse, "My neighbors are spying on me because they want to rob me and take money." While hospitalized, the client complains of being poisoned by the food and of being given the wrong medication. The nurse evaluates the client’s response to medications and therapy. Which finding leads the nurse to conclude that the client’s reality testing has improved?

The client eats the food provided on the hospital tray.

A client with major depression that includes psychotic features tells the nurse, "All of my relatives have been killed because I’ve been sinful and need to be punished." What is the primary focus of nursing interventions?

Protecting the client against any suicidal impulses

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to evaluate?

Dehydration -The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle.

Evaluation of clients with anorexia nervosa requires reassessment of behaviors after admission. Which finding indicates that the therapy is beginning to be effective?

The client has gained 6 lb since admission 3 weeks ago. -Weight gain of 6 lb since admission 3 weeks ago is objective proof that the client’s eating behaviors have improved

A client who attempted suicide by slashing her wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implanted when the client arrives on the unit? (Select all that apply.)

1. Obtaining vital signs 2. Assessing for suicidal thoughts 3. INstituting continuous monitoring 4. Initiating a therapeutic relationship 5. Inspecting the bandages for bleeding

A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client’s room. What should the nurse say when it is time for the client to go for a walk?

"It’s time for you to go for a walk now."

A daycare environment is recommended for a client with incapacitating behaviors resulting from an obsessive-compulsive personality disorder. The client’s partner asks the nurse why this approach is necessary. What is the best response by the nurse?

"A neutral atmosphere facilitates the working through of conflicts." -These clients can better work through their underlying problems when the environment is structured, demands are reduced, and the routine is simple

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. This means that these children:

Experience perceptual difficulties that interfere with learning -ADHD interferes with the ability to perceive and respond to sensory stimuli, resulting in a deficit in interpreting new sensory data. This makes learning difficult. It is not true that children with ADHD have intellectual deficits that interfere with learning; there is no cognitive impairment present.

Without knocking, a nurse enters the room of a young male client with the diagnosis of panic disorder and finds him masturbating. What should the nurse do?

Apologize and leave the room

One morning a nurse on the psychiatric unit finds a client curled up in the fetal position in the corner of the dayroom. What is an appropriate initial inference for the nurse to make about the client?

The client is feeling more anxious today.

While speaking with a client with schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. What is the best response by the nurse?

"I’d like to understand what you’re saying, but I’m having difficulty following you."

A nurse is caring for a client with the diagnosis of schizophrenia, paranoid type. How should the nurse plan for the client’s initial care?

By providing a nonthreatening environment

On the day after admission a suicidal client asks a nurse, "Why am I being watched around the clock, and why can’t I walk around the whole unit?" Which reply is most appropriate?

"We’re concerned that you might try to harm yourself."

The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate response by the nurse?

Informing the client in a matter-of-fact tone that everyone must remain with the group

How should the nursing staff fulfill the nutritional needs of a client experiencing periods of extreme mania and hyperactivity?

Offering high-calorie snacks frequently that the client can hold

The parents of a young adult client visit regularly. After one visit the client becomes very agitated. What should the nurse do to relieve the client’s distress?

Explore the client’s response to the parents’ behavior

A nurse is discharging a client from the mental health unit who has been treated for major depression. Which statement is most therapeutic at this time?

"Call the contact number we gave you if you have an emergency."

A nurse is caring for a group of depressed clients. What should the nurse attempt to provide?

An uncomplicated daily schedule

A 7-year-old boy is brought to the clinic by the mother, who tells the nurse that her child has been having trouble in school, has difficulty concentrating, and is falling behind in schoolwork since she and her husband separated 6 months ago. The mother reports that lately her child has not been eating dinner, and she often hears him crying when he is alone. What basis for these behaviors should the nurse consider?

The child may be blaming himself for his parents’ breakup.

A hospitalized psychiatric client with the diagnosis of histrionic personality disorder demands a sleeping pill before going to bed. After being refused the sleeping pill, the client throws a book at the nurse. The nurse identifies this behavior as:

Acting out

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." Initial nursing care should be focused on the client’s:

Potential for self-harm

A nurse is caring for a client with the diagnosis of dementia. What should the nurse ask the client to best ascertain orientation to place?

"Where are you?"

A nurse is caring for a client with the diagnosis of bipolar disorder, manic episode. The health care provider prescribes divalproex sodium (Depakote) 375 mg twice a day by mouth. The Depakote is labeled "250 mg/5 mL." How many milliliters of solution should the nurse administer per dose? Record your answer using one decimal place. __________ mL

Use the "desired over have" formula of ratio and proportion. Desired 375 mg x mL ——————– = ——– Have 250 mg 5 mL 250x = 1875 x = 1875 ÷ 250 x = 7.5 mL

Risk for assaultive behavior is highest in the mental health client who:

Experiences command hallucinations

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care?

Routines provide stability for clients with dementia.

When attempting to evaluate the behavior of an older adult with a diagnosis of vascular dementia, a nurse knows that the client is probably:

Making exaggerated use of old, familiar mechanisms

After working for a week with an adolescent with anorexia nervosa, the adolescent becomes hostile and says to the nurse, "You’re just like my mother. I hate you." What concept does the client’s statement reflect?

Transference

A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD?

Early onset, before 36 months of age -Autism impairs bonding and communication and therefore becomes apparent early in life. Autism involves both delayed and deviant linguistic problems. About 25% of children with autism have a seizure disorder. Autism may, and often does, include cognitive impairment.

When a client is expressing severe anxiety by sobbing in the fetal position on her bed, the nurse’s priority is:

Ensuring a safe therapeutic milieu

A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse?

"You sound upset about not being able to have an erection."

A client with agitation and mood swings approaches the nurse and shouts, "I’ve been watching you for a few days. You think you’re so damned perfect and good. I think you stink!" What is the most appropriate response by the nurse?

"You seem to be angry with me."

A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing?

Somatic delusion

Suicide precautions are ordered for a newly admitted client. What is the most therapeutic way to provide these precautions?

Assigning a staff member to be with the client at all times -Emotional support and close surveillance can demonstrate the staff’s caring and their attempt to prevent the client from acting out of suicidal ideation. Although surveillance may meet the client’s safety needs, it does not meet the client’s emotional needs. Also, the client would still have the opportunity to attempt suicide at night. Encouraging the client to express feelings frequently is not a suicide precaution.

A client tells the nurse, "I used to believe that I was a princess, but now I know that that’s not true." What is the best response by the nurse?

"That’s is a sign that you’re getting better."

An older client with the diagnosis of dementia, Alzheimer type, is admitted to a nursing home. The client is confused and forgetful, wanders, and has intermittent episodes of urinary incontinence. How should the nurse plan to meet this client’s elimination needs?

By taking the client to the bathroom at regular intervals -Taking the client to the bathroom at regular intervals removes responsibility from the client, who is having difficulty recognizing and remembering to follow through on basic needs; routinely emptying the bladder may reduce episodes of incontinence.

What is the best initial nursing approach to take with a self-accusatory, guilt-ridden client?

Accepting the client’s statements as the client’s beliefs -The nurse must accept the client’s statement and beliefs as real to the client to develop trust and move toward a therapeutic relationship. Clients cannot be argued out of delusions. These feelings and thoughts are constant; medicating the client whenever they are expressed could result in an overdose. Redirecting the client’s conversation whenever negative topics are brought up may cut off conversation and the development of trust.

Encouragement and appropriate praise should be given to hyperactive clients to help them increase their feelings of self-esteem. When they have acted appropriately, what is the best statement for the nurse to make in an effort to let them know of their improvement?

"You behaved well today." -"You behaved well today" simply states a fact and delivers praise without making demands.

A client with generalized anxiety disorder says to the nurse, "What can I do to keep myself from overreacting to stress?" What is the best response by the nurse?

"Work on identifying and developing coping strategies."

An older adult resident of a nursing home who has the diagnosis of dementia of the Alzheimer type, frequently talks about the good old days at the ranch. What is the most appropriate action by the nurse?

Allowing the resident to reminisce about the past and listening with interest

A client has been in an acute care psychiatric unit for 3 days and is receiving haloperidol (Haldol) tablets orally to reduce agitation and preoccupation with auditory hallucinations. There has been no decrease in the client’s agitation or preoccupation with auditory hallucinations since the medication was started. What should the nurse’s priority intervention be?

Making certain that the client is swallowing the medication

When caring for clients who are at risk for suicide, the nurse should consider that:

Formal suicide plans increase the likelihood that a client will attempt suicide.

A client with the diagnosis of schizophrenia watches the nurse pour juice for the morning medication from an almost-empty pitcher and screams, "That juice is no good! It’s poisoned." What is the most therapeutic response by the nurse?

Remarking, "You sound frightened. Is there something else I can give you to take your medication with?" -The response "You sound frightened" reflects the client’s feelings and avoids focusing on the delusion; following up with "Is there something else I can give you to take your medication with?" encourages the client to take the medication

A nurse identifies the establishment of trust as a major nursing goal for a depressed client. How can this goal best be accomplished?

By visiting frequently for short periods with the client each day

When answering questions from the family of a client with Alzheimer disease the nurse explains that the disease:

Is a slow, relentless deterioration of the mind

A client in the outpatient clinic is denying that he is addicted to alcohol. He tells the nurse that he is not an alcoholic and that it is his nagging wife who causes him to drink. What is the most therapeutic response by the nurse?

"Everyone is responsible for his own actions."

A client undergoing alcohol detoxification asks about attending Alcoholics Anonymous (AA) meetings after discharge. What is the nurse’s best initial reply?

"How do you feel about going to those meetings?"

A nurse is caring for a female client during the manic phase of a bipolar disorder. What should the nurse do to help the client with personal hygiene?

Guide her to dress appropriately in her own clothing

A client is admitted to the psychiatric service with a diagnosis of severe depression. When approached by the nurse, the client says, "You know I’m a sorry, lazy person. I don’t deserve a job. I’m just stupid and no good." What does the nurse conclude that the client is experiencing?

Feelings of self-deprecation

The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse’s conclusion that the client is experiencing hopelessness? (Select all that apply.)

1 Bouts of crying 2 Self-destructive acts 4 Feelings of worthlessness

What should the nurse include when planning activities for an older nursing home resident with a diagnosis of dementia?

Familiar activities that the resident can complete successfully

On the fifth day of hospitalization the nurse notes that a depressed client remains lying on her bed when the clients are called to the dining room for lunch. What should the nurse do to encourage the client to eat?

Offer to accompany the client to the dining room

A client’s admitting history indicates signs of akathisia. What clinical finding should the nurse expect when observing for this condition?

Motor restlessness

A hyperactive, acting-out 9-year-old boy is started on a behavior modification program in which tokens are given for acceptable behavior. When he begins to lose a game he is playing with other children, he begins to kick the other children under the table and call them names. What is the most appropriate behavior modification technique for the nurse to use?

Placing the child in a short time-out

What clinical manifestation best indicates to the nurse that the mental status of a client with the diagnosis of schizophrenia, paranoid type, is improving?

Ability to function effectively in activities of daily living

A depressed client is very resistive and complains about inabilities and worthlessness. The best nursing approach is to:

Involve the client in activities in which success can be ensured

A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis?

Disordered thinking

What childhood problem has legal as well as emotional aspects and cannot be ignored?

School phobia

A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention?

Avoiding focusing on the client’s physical symptoms

A client demonstrating manic behavior is elated and sarcastic. The client is constantly cursing and using foul language and has the other clients on the unit terrified. Initially the nurse should:

Tell the client firmly that the behavior is unacceptable

What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol?

Motivational readiness

An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis?

Argues with adults

A practitioner prescribes disulfiram (Antabuse) for a client who abuses alcohol. The nurse remembers that disulfiram will:

Cause a severe adverse reaction if alcohol is consumed

A nurse determines that a client is pretending to be ill. What does this behavior usually indicate?

Malingering

During the admission procedure a client appears to be responding to voices. The client cries out at intervals, "No, no! I didn’t kill him! You know the truth — tell that police officer! Please help me!" What is the most appropriate response by the nurse?

Saying, "I want to help you. I realize that you must be very frightened."

A client tells the nurse, "All my friends experiment with drugs. I like the high I get when I huff paint. Nothing bad is going to happen to me." What is the best response by the nurse?

"Huffing paint can damage your lungs, kidneys, and liver."

At a staff meeting, the question of a staff nurse’s returning to work after completing a drug rehabilitation program is discussed. What is the most therapeutic way for the staff to handle the nurse’s return?

Offering the nurse support in a straightforward manner

A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child’s birth 3 years ago. What is most directly related to the client’s loss of interest in sex?

Depression

The parents of an adolescent girl are upset about their daughter’s diagnosis of anorexia nervosa and the treatment plan that has been proposed. What is the best response by the nurse when the client’s parents ask to bring food in for the client?

"For now, let the staff handle her food needs."

A nurse on a mental health unit has developed a therapeutic relationship with a manipulative, acting-out client. One day as the nurse is leaving, the client says, "Please stay. I’m afraid that the evening staff doesn’t like me. They’re always punishing me." What is the nurse’s most therapeutic response?

"You know I leave at this time. We’ll talk about this in the morning.

A nurse is planning care for a depressed client. Which approach is most therapeutic?

Allowing the client time to complete activities

What clinical findings may be expected when a nurse cares for an individual with an anxiety disorder? (Select all that apply.)

1 Worrying about a variety of issues 3 Converting the anxiety into a physical symptom 4 Displacing the anxiety onto a less threatening object 5 Demonstrating behavior common to an earlier stage of development

A client is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After a 1-month hospitalization the client is discharged home with instructions to continue the antipsychotic and a referral for weekly mental health counseling. The picture illustrates the client’s physical status as observed by the nurse on the client’s first visit to the community mental health clinic. What extrapyramidal side effect has developed?

Akathisia

According to Erikson, a child’s increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage?

Trust

With the client’s permission, the nurse should inform the family about what is happening. The main reason for this action is that informed families:

Are better equipped to assist the client

A 19 year-old, arrested for assault and robbery, has a history of truancy and prostitution but is unconcerned that her behavior has caused emotional distress to others. The diagnosis of antisocial personality disorder is made. According to psychoanalytical theory, the client’s lack of remorse and repetitive behavior probably are related to an underdeveloped:

Superego

A male client with dementia due to Parkinson’s disease has been placed in a nursing home. His wife appears tired and angry on her first visit with her husband. As she is leaving she says to the unit nurse in a sarcastic tone, "Let’s see what you can do with him." What is the most therapeutic response by the nurse?

"It sounds like it’s been difficult for you."

A client has become increasingly depressed, and the practitioner prescribes an antidepressant. After 20 days of therapy, the client returns to the clinic. The client appears relaxed and smiles at the nurse. The most significant conclusion that the nurse can draw from this behavior is that the client:

Is responding to the antidepressant therapy

A hospitalized 7-year-old boy wakes up crying because he has wet his bed. It is most appropriate for the nurse to:

Change the child’s bed while he changes his pajamas

A client with cancer is told by a health care provider that the cancer has metastasized to other organs and is untreatable. The client tells the nurse, "I think they made a mistake. I don’t think I have cancer. I feel too good to be dying." Which stage of grief does the nurse conclude that the client is experiencing?

Denial

A nurse is caring for a client who is experiencing a crisis. Which nervous system is primarily responsible for the clinical manifestations that the nurse is likely to identify?

Sympathetic nervous system

A client is extremely depressed, and the practitioner prescribes a tricyclic antidepressant, imipramine (Tofranil). The client asks the nurse what the medication will do. The nurse responds:

"It will help increase your appetite and make you feel better.

What developmental task should the nurse consider when caring for toddlers?

Autonomy

A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to observe the client for side effects. What is the nurse’s initial action?

checking the client’s blood pressure

What is the most difficult initial task in the development of a nurse-client relationship?

Developing an awareness of self and the professional role in the relationship

A practitioner prescribes Alprazolam (Xanax) 0.25 mg by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For what most common side effect of this drug should the nurse monitor the client?

Drowsiness

During a group discussion regarding the unexpected suicide of a young female client who was on a weekend pass, one of the other clients stands up and shouts, "Oh, I know what you’re all thinking. You think that I should’ve known that she was going to kill herself. You think I helped her plan this." What is the most therapeutic response by the group leader?

"You’re upset because you think we’re blaming you for her death?

A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. The nurse should:

Refer the mother to the psychiatrist

A client who is being treated in a mental health clinic is to be discharged after several months of therapy. The client anxiously tells the nurse, "I don’t know what I’ll do when I can’t see you anymore." The nurse determines that the client is:

Reacting to the planned discharge

Which individual is coping with issues concerning dependence versus independence?

Toddler

An older client who lost a spouse 20 years ago comes to the community health center with a vague list of complaints and a brief life history. The couple’s only child died at birth. The client lives alone and is able to perform all the activities of daily living. The client has had an active social life in the past but has outlived many friends and family members. What is an important question for the nurse to ask when taking this client’s health history?

"How do you feel about your life now?"

What is the most important tool a nurse brings to the therapeutic nurse-client relationship?

The self and a desire to help

As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because, she says, "I have nothing to talk about." What is the best response by the nurse?

"You feel you won’t be accepted unless you have something to say?"

A nurse is caring for a client who has abruptly stopped taking a barbiturate. What should the nurse anticipate that the client may experience?

Seizures

A primary nurse notes that a client has become jaundiced after 2 weeks of antipsychotic drug therapy. The nurse continues to administer the antipsychotic until the health care provider can be consulted. What does the nurse manager conclude about this situation?

Jaundice is sufficient reason to discontinue the antipsychotic

A client has just spent five minutes complaining to the nurse about numerous aspects of the client’s hospital stay. Which is the best initial response by the nurse?

Refocus the conversation on the client’s fears, frustrations, and anger about the client’s condition

A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse’s response?

A client is allowed to consent to or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs

A 23-year-old woman is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents’ home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, "People like that need to be put away before they kill someone." The nurse concludes that the client is using:

Projection

The emergency department nurse is conducting an interview and assisting with the physical examination of a female sexual assault victim. What is most important for the nurse to document on this client’s record?

Statements by the client about the sexual assault and the rapist

A female client in the mental health clinic has pressured speech and mumbles incoherently. What is the most appropriate nursing intervention?

Indicating to the client that she needs to slow down because what she says is important and cannot be understood

The way individuals cope with an unexpected hospitalization depends on many factors. However, the one that is most significant is

Basic personality

A client is receiving a monoamine oxidase inhibitor (MAOI). What should the nurse teach the client?

Many prescribed and over-the-counter drugs cannot be taken with this medication.

A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example?

Dissociation

A nurse’s best approach when caring for a confused older client is to provide an environment with:

Trusting relationships

A group of clients from a psychiatric unit, accompanied by staff members, are going to a professional baseball game. The purpose of visits into the community under the supervision of staff members is:

Observing the clients’ abilities to cope with a more complex society

A client who has been admitted to the hospital for an elective prostatectomy is extremely anxious and has hand tremors. The client’s partner informs the nurse that the client has been drinking heavily for the last 5 years. While the client is unpacking the nurse sees him hiding a bottle of whiskey in the rear of a drawer. How should the nurse respond initially to this behavior?

Asking the client how much alcohol he consumes in a week

A health care provider diagnoses attention deficit-hyperactivity disorder (ADHD) in a 7-year-old child and prescribes methylphenidate (Ritalin). The nurse discusses the child’s treatment with the parents. What should the nurse emphasize as important for the parents to do?

Monitor the effect of the medication on their child’s behavior

In what situation should a nurse anticipate that a client will experience a phobic reaction?

When coming into contact with the feared object

Which nursing action is most important when providing counseling to an adolescent with anorexia nervosa?

Helping the client express concerns about body image

A depressed client resists becoming involved in an activity, complains that he can’t do anything well, and claims to be worthless. What is the best approach by the nurse?

Involving the client in an activity in which success can be ensured

A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates that she is hearing voices. When a nurse begins to walk toward her, the client pulls out a large knife. What is the best approach by the nurse?

Firm

A man is admitted to the psychiatric unit after attempting suicide. The client’s history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing?

Command hallucination

The mother of an 18-year-old man comes to the local mental health center. She is extremely upset because of her son’s behavior since the young man returned from his freshman year at college. He takes his brother’s clothing, comes in at all hours, and refuses to get a job. Sometimes he is happy and outgoing, but at other times he is withdrawn. The mother asks why her son is like this. While contemplating this situation, the nurse considers that adolescents are usually:

Impulsive and self-centered

A client who experiences auditory hallucinations agrees to discuss alternative coping strategies with a nurse. For the next 3 days when the nurse attempts to focus on alternative strategies, the client gets up and leaves the interaction. What is the most therapeutic response by the nurse?

"You seem very uncomfortable every time I bring up a new way to cope."

A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel:

Angry

A client has been prescribed lithium. What important nursing intervention must be implemented while this medication is being administered?

Regularly testing the level of the drug in the client’s blood

A client is using ritualistic behaviors. Why should a nurse give the client ample time in which to perform the ritual?

Denial of this activity may precipitate a panic level of anxiety.

A 10-year-old child in whom autism was diagnosed at the age of 3 attends a school for developmentally disabled children and lives with his parents. The child has frequent episodes of self-biting and head-banging and needs help with feeding and toileting. The priority nursing goal for this child is:

Remaining safe from self-inflicted injury

After 4 days on the inpatient psychiatric unit a client on suicidal precautions tells the nurse, "Hey, look! I was feeling pretty depressed for a while, but I’m certainly not going to kill myself." What is the nurse’s best response to this statement?

"We should talk some more about this."

A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place the following interventions in priority order, from the least to the most restrictive.

1. Diversional activities 2. Limit-setting 3. Medication administration 4. Seclusion 5. Restraints

A nurse is planning to teach a client about self-care. What level of anxiety will best enhance the client’s learning abilities?

Mild

A client who is being treated for schizophrenia, paranoid type, arrives at the clinic demonstrating a shuffling gait and tilting his head toward one shoulder. What should the nurse conclude about these clinical manifestations?

Possible side effects of the antipsychotic medication

A delusional client verbalizes the belief that others are out to harm him. A nurse notes the client’s worsening pacing and agitation. What is the best nursing intervention?

Moving the client to a quiet place on the unit

What is important when the nurse plans care for a client with paranoid ideation?

Providing the client with opportunities for nonthreatening social interaction

A depressed client often sleeps past the expected time of awakening and spends excessive time resting and sleeping. Which nursing intervention is appropriate for this client?

Restricting the client’s access to the bedroom

A depressed client is concerned about many fears that are upsetting and frightening and expresses a feeling of having committed the "unpardonable sin." What is the most therapeutic response by the nurse?

"Your thoughts are just a part of your illness, and they’ll change as you get better."

One morning a female client with the diagnosis of schizophrenia tells the nurse that she is Joan of Arc and is going to be burned at the stake. What is the most therapeutic response by the nurse?

"It seems like the world is a pretty scary place for you."

An 18 year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that flunitrazepam is often used:

As a date rape drug

A nurse recalls that in a conversion disorder, pseudoneurological symptoms such as paralysis or blindness:

Are generally necessary for the client to cope with a stressful situation

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. When planning care for this client, the nurse recalls that confusion:

Occurs with a transfer to new surroundings

A nurse is caring for a client who has been hospitalized for alcohol withdrawal. The client decides to attend an Alcoholics Anonymous meeting. What is a basic principle of this group?

Amends must be made to each person who has been harmed.

A woman who gave birth to a second child 3 weeks ago is depressed and having difficulty caring for her children. At the end of the day both of the children are dirty, wet, and crying. The woman tells her husband that she "just can’t take this anymore." The husband calls the women’s health clinic and asks what he should do. What is the best response by the nurse?

Telling him that his wife may be suffering from depression and needs emergency care

What therapeutic nursing intervention may redirect a hyperactive, manic client?

Encouraging the client to tear pictures out of magazines for a scrapbook