A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply).
A. “To assess cognitive ability, I should ask the client to count backward by sevens.”
B. “To assess affect, I should observe the client’s facial expression.
C. “To assess language ability, I should instruct the client to write a sentence.”
D. “To assess remote memory, I should have the client repeat a list of objects.”
E. “To assess the client’s abstract thinking, I should ask the client to identify our most recent presidents.”
A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications.
D. Monitor the client for adverse effects of the medications.
A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority?
A. Coordinate holistic care with social services
B. Identify the client’s perception of her mental health status.
C. Include the client’s family in the interview.
D. Teach the client about her current mental health disorder.
B. Identify the client’s perception of her mental health status.
A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place.
A. The client arouses briefly in response to a sternal rub.
A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion? (Select all that apply)
A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders.
D. The DSM-5 assists nurses in planning care for client’s who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod
D. A client who has bipolar disorder and paces quickly around the room while talking to himself
C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse’s actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery
A client tells a nurse, “Don’t tell anyone but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me.” Which of the following actions should the nurse take?
A. Keep the client’s communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife
B. Keep the client’s communication confidential, but watch the client and his roommate closely.
C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of the intention to do so.
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply)
A. “Client ate most of his breakfast.”
B. “Client was offered 8 oz of water every hr.”
C. “Client shouted obscenities at assistive personnel.”
D. “Client received chlorpromazine 15 mg by mouth at 1000.”
E. “Client acted out after lunch.”
A nurse hears a newly licensed nurse discussing a client’s hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?
A. Notify the nurse manager.
B. Tell the nurse to stop discussing the behavior.
C. Provide an in-service program about confidentiality.
D. Complete an incident report.
B. Tell the nurse to stop discussing the behavior
A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son’s condition, which of the following responses should the nurse make?
A. “I think your son is getting better. What have you noticed.”
B. “I’m sure everything will be okay. It just takes time to heal.”
C. “I’m not sure whats wrong. Have you asked the doctor about your concerns?”
D. “I understand you’re concerned. Let’s discuss what concerns you specifically.”
D. “I understand you’re concerned. Let’s discuss what concerns you specifically.”
A nurse is caring for a client who smokes and has lung cancer. The client reports, “I’m coughing because I have that cold that everyone has been getting.” The nurse should identify that the client is using which of the following defense mechanisms?
A. Reaction formation
B. Denial
C. Displacement
D. Sublimation
A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client has a respiratory rate 30/min and says, “This is difficult to comprehend. I feel shaky and nervous.” The nurse should identify that the client is experiencing which of the following levels of anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.)
A. Reassure the client that everything will be okay.
B. Discuss prior use of coping mechanisms with the client.
C. Ignore the client’s anxiety so that she will not be embarrassed.
D. Demonstrate a calm manner while using simple and clear directions.
E. Gather information from the client using closed-ended questions.
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make?
A. “I feel very sorry for the loneliness you must be experiencing.”
B. “Suicide is not the appropriate way to cope with loss.”
C. “Losing someone close to you must be very upsetting.”
D. “I know how difficult it is to lose a loved one.”
C. “Losing someone close to you must be very upsetting.”
A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply)
A. The needs of both participants are met.
B. An emotional commitment exists between the participants.
C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.
C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.
A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior?
A. The client asks the nurse whether she will go out to dinner with him.
B. The client accuses the nurses of telling him what to do just like his ex-girlfriend.
C. The client reminds the nurse of a friend who died from a substance overdose.
D. The client becomes angry and threatens to harm himself.
B. The client accuses the nurses of telling him what to do just like his ex-girlfriend.
A. Discussing ways to use new behaviors
A nurse is orienting a new client to a mental health unit. When explaining the unit’s community meetings, which of the following statements should the nurse make?
A. “You and a group of other clients will meet to discuss your treatment plans.
B. “Community meetings have a specific agenda that is established by staff.
C. “You and the other clients will meet with staff to discuss common problems.
D. “Community meetings are an excellent opportunity to explore your personal mental health issues.”
C. “You and the other clients will meet with staff to discuss common problems.
A nurse is caring several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first?
A. A client who recently burned her arm while using a hot iron at home.
B. A client who requests that her antipsychotic medication be changed due to some new adverse effects.
C. A client who says he is hearing a voice that tells him he is not worth living anymore.
D. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview.
C. A client who says he is hearing a voice that tells him he is not worth living anymore.
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention?
A. Educating clients on health promotion techniques to reduce the risk of depression
B. Performing screenings for depression at community health programs
C. Establishing rehabilitation programs to decrease the effects of depression
D. Providing support groups for clients at risk for depression
C. Establishing rehabilitation programs to decrease the effects of depression
A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client’s wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow-up care?
A. Receiving daily care from a home health aide
B. Having a weekly visit from a nurse case worker
C. Attending a partial hospitalization program
D. Visiting a community mental health center on a daily basis
C. Attending a partial hospitalization program
A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group?
A. A client in an cute care mental health facility who has fallen several times while running down the hallway
B. A client who lives at home and keeps “forgetting” to come in for his monthly antipsychotic injection for schizophrenia
C. A client in a day treatment program who says he is becoming more anxious during group therapy
D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months
A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy?
A. “Even if my anxiety improves, I will need to continue this therapy for 6 weeks.
B. “The therapist will focus on my past relationships during our sessions.”
C. “Psychoanalysis will help me reduce my anxiety by changing my behaviors.”
D. “This therapy will address my conscious feelings about stressful experiences.”
B. “The therapist will focus on my past relationships during our sessions.”
A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique?
A. “I will write down my dreams as soon as I wake up.”
B. “I may begin to associate my therapist with important people in my life.”
C. “I can learn to express myself in a nonaggressive manner.”
D. “I should say the first thing that comes to my mind.”
D. “I should say the first thing that comes to my mind.”
27. A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care? (Select all that apply)
A. Priority restructuring
B. Monitoring thoughts
C. Diaphragmatic breathing
D. Journal keeping
E. Meditation
A. Priority restructuring
B. Monitoring thoughts
D. Journal keeping
A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. Which of the following types of treatment is this method an example?
A. Aversion therapy
B. Flooding
C. Biofeedback
D. Dialectical behavior therapy
A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy?
A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior.
B. Advise the client to say “stop” out loud every time he begins to feel an anxiety response related to an elevator.
C. Gradually expose the client to an elevator while practicing relaxation techniques.
D. Stay with the client in an elevator until his anxiety response diminishes.
C. Gradually expose the client to an elevator while practicing relaxation techniques.
A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions?
A. Observes group techniques without interfering with the group process
B. Discusses a technique and then directs members to practice the technique
C. Asks for group suggestions of techniques and then support discussion
D. Suggests techniques and asks group members to reflect on their use
E. Democratic leadership supports group interaction and decision making to solve problems.
A. Observes group techniques without interfering with the group process
A nurse is planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase? (Select all that apply)
A. Encourage the group to work toward goals
B. Define the purpose of the group
C. Discuss termination of the group
D. Identify informal roles of members within the group
E. Establish an expectation of confidentiality within the group
A nurse working on an acute mental health unit forms a group to focus on self-management of medications. At each of meetings, two of the members use the opportunity to discuss their common interest in gambling on sports. This is an example of which of the following concepts?
A. Triangulation
B. Group process
C. Subgroup
D. Hidden agenda
A nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he’s the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following?
A. Placation
B. Manipulation
C. Blaming
D. Distraction
A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role?
A. A member who praises input from other members
B. A member who follows the direction of other members
C. A member who brags about accomplishments
D. A member who evaluates the group’s performance toward a standard
C. A member who brags about accomplishments
A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse include in the discussion?
A. Excessive stressors cause the client to experience distress.
B. The body’s initial adaptive response to stress is denial.
C. Absence of stressors results in homeostasis.
D. Negative, rather than positive, stressors produce a biological response.
A. Excessive stressors cause the client to experience distress.
A. Chronic pain
B. Depressed immune system
E. Unhappiness
A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?
A. “Cognitive reframing will help me change my irrational thoughts to something positive.
“B. “Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate.
“C. “Biofeedback causes my body to release endorphins so that I feel less stress and anxiety.
“D. “Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety.”
A. “Cognitive reframing will help me change my irrational thoughts to something positive.”
A client says she is experiencing increased stress because her significant other is “pressuring me and my kids to go live with him. I love him, but I’m not ready to do that.” Which of the following recommendations should the nurse make to promote a change in the client’s situation?
A. Learn to practice mindfulness
B. Use assertiveness techniques
C. Exercise regularly
D. Rely on the support of a close friend
B. Use assertiveness techniques
A nurse is caring for a client who states, “I’m so stressed at work because of my coworker. He expects me to finish his work because he’s too lazy!” When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding?
A. “You really should complete your own work. I don’t think it’s right to expect me to complete your responsibilities.
“B. “Why do you expect me to finish your work? You must realize that I have my own responsibilities.
“C. “It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor.
“D. “When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities.”
A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?
A. “It is common to treat depression with ECT before trying medications.”
B. “I can have my depression cured if I receive a series of ECT treatments.”
C. “I should receive ECT once a week for 6 weeks.”
D. “I will receive a muscle relaxant to protect me from injury during ECT.”
D. “I will receive a muscle relaxant to protect me from injury during ECT.”
A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “TMS is indicated for clients who have schizophrenia spectrum disorders.”
B. “I will provide postanesthesia care following TMS.”
C. “TMS treatments usually last 5-10 minutes.”
D. “I will schedule the client for daily TMS treatments for the first several weeks.”
“I will schedule the client for daily TMS treatments for the first several weeks.”
C. Memory loss
D. Nausea
E. Confusion
A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion?
A. Borderline personality disorder
B. Acute withdrawal related to a substance use disorder
C. Bipolar disorder with rapid cycling
D. Dysphoric disorder
C. Bipolar disorder with rapid cycling
A. Voice changes
D. Dysphagia
E. Neck pain
A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?
A. Narcissistic behavior
B. Fear of rejection from staff
C. Attempt to reduce anxiety
D. Adverse effect of antidepressant medication
D. Stay with the client and remain quiet
A. Excessive worry for 6 months
D. Restlessness
E. Need for reassurance
A nurse is caring for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?
A. Assessing the client’s risk for self harm
B. Instilling hope for positive outcomes
C. Encouraging the client to participate in group therapy sessions
D. Encouraging the client to participate in treatment decisions
A. Assessing the client’s risk for self harm
A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements should the nurse make?
A. “Tell me about how you are feeling right now.”
B. “You should focus on the positive things in your life to decrease your anxiety.”
C. “Why do you believe you are experiencing this anxiety?”
D. “Let’s discuss the medications your provider is prescribing to decrease your anxiety.”
A. “Tell me about how you are feeling right now.”
A nurse working on an acute mental health unit is caring for a client who has PTSD. Which of the following findings should the nurse expect? (Select all that apply)
A. Difficulty concentrating on tasks
B. Obsessive need to talk about the traumatic event
C. Negative self-image
D. Recurring nightmares
E. Diminished reflexes
A. Difficulty concentrating on tasks
C. Negative self-image
D. Recurring nightmares
A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply)
A. Avoid thinking about the incident when it is over
B. Take breaks during the incident for food and water
C. Debrief with others following the incident
D. Hold emotions in check in the days following the incident
E. Take advantage of offered counseling
A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect?
A. The client remembers many details about the traumatic incident
B. The client expresses heightened elation about what is happening
C. The client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred.
D. The client expresses a sense of unreality about the traumatic event
D. The client expresses a sense of unreality about the traumatic event
A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?
A. The client explains that her body seems to be floating above the ground
B. The client has the idea that someone is trying to kill her and steal her money
C. The client states that the furniture in the room seems to be small and far away
D. The client cannot recall anything that happened during the past 2 weeks
C. The client states that the furniture in the room seems to be small and far away
A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?
A. Teach the client to recognize how stress brings on a personality change in the client
B. Repeatedly present the client with information about past events
C. Make decisions for the client regarding routine daily activities
D. Work with the client on grounding techniques
D. Work with the client on grounding techniques
A nurse working in an acute mental health facility is caring for a 35-year-old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (Select all that apply)
A. Age
B. Gender
C. History of chronic asthma
D. Smoking
E. Being married
A. Age
B. Gender
C. History of chronic asthma
E. Being married
A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse’s priority?
A. Placing the client on one-to-one observation
B. Assisting the client to perform ADLs
C. Encouraging the client to participate in counseling’
D. Teaching the client about medication adverse effects
A. Placing the client on one-to-one observation
A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?”
A. “I can expect my problems with PMDD to be worst when I’m menstruating.”
B. “I will use light therapy 30 min a day to prevent further recurrences of PMDD.”
C. “I am aware that my PMDD causes me to have rapid mood swings.”
D. “I should increase my caloric intake with a nutritional supplement when my PMDD is active.”
C. “I am aware that my PMDD causes me to have rapid mood swings.”
A charge nurse is discussing the care of a client who has MDD with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “Care during the continuation phase focuses on treating continued manifestations of MDD.
“B. “The treatment of MDD during the maintenance phase lasts for 6-12 weeks.
“C. “The client is at greatest risk for suicide during the first weeks of an MDD episode.
“D. “Medication and psychotherapy are most effective during the acute phase of MDD.”
C. “The client is at greatest risk for suicide during the first weeks of an MDD episode.
A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymic disorder. Which of the
following findings should the nurse expect?
A. Wide fluctuations of mood
B. Report of a minimum of 5 clinical findings of depression
C. Presence of manifestations for at least 2 years
D. Inflated sense of self-esteem
C. Presence of manifestations for at least 2 years
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply
)’
A. Provide flexible client behavior expectations ‘
B . Offer concise explanations
C. Establish consistent limits
D. Disregard client complaints
E. Use a firm approach with communication
B. Offer concise explanations
C. Establish consistent limits
E. Use a firm approach with communication
A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?
”A. “ECT is the recommended initial treatment for bipolar disorder.
B. “ECT is contraindicated for clients who have suicidal ideation”
C. “ECT is effective for client’s who are experiencing severe mania.””
D. “ECT is prescribed to prevent relapse of bipolar behavior.”
“ECT is effective for client’s who are experiencing severe mania.”‘
A nurse is caring for a client who has bipolar disorder. The client states, “I am very rich, and I feel I must give my money to you.” Which of the following responses should the nurse make?
A. “Why do you think you feel the need to give money away?”
B. “I am here to provide care and cannot accept this from you”
C. “I can request that your case manager discuss appropriate charity options with you.”
D. “You should know that giving away your money is inappropriate.”
B. “I am here to provide care and cannot accept this from you”
A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?
A. Set consistent limits for expected client behavior’
B. Administer prescribed medications as scheduled
C. Provide the client with step by step instructions during hygiene activities
D. Monitor the client for escalating behavior
D. Monitor the client for escalating behavior
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply)
A. Use caffeine in moderation to prevent relapse
B. Difficulty sleeping can indicate a relapse
C. Begin taking your medications as soon as a relapse begins
D. Participating in psychotherapy can help prevent a relapse
E. Anhedonia is a clinical manifestation of a depressive relapse
A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, “The voices won’t leave me alone!” Which of the following statements should the nurse make? (Select all that apply)
A. “When did you start hearing the voices?”
B. “The voices are not real, or else we would both hear them.”
C. “It must be scary to hear voices.”
D. “Are the voices telling you to hurt yourself?”
E. “Why are the voices talking to only you?”
A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply)
A. Auditory hallucination
B. Lack of motivation
C. Use of clang association
D. Delusion of persecution.
E. Constantly waving arms.
F) Flat affect
A. Auditory hallucination
C. Use of clang association
D. Delusion of persecution.
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?
A. “I am a superhero and am immortal.
B. “I am no one, and everyone is me.”
C. “I feel monsters pinching me all over.
D. “I know that you are stealing my thoughts.”
B. “I am no one, and everyone is me.”
A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to “kill your doctor”. Which of the following actions should the nurse take first?
A. Use therapeutic communication to discuss the hallucination with the client
B. Initiate one-to-one observation of the client
C. Focus the client on reality
D. Notify the provider of the client’s statement
B. Initiate one-to-one observation of the client
A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse’s questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take?
A. Stop the interview at this point, and resume later when the client is better able to concentrate.
B. Ask the client, “Are you seeing something on the ceiling?”
C. Tell the client, “You seem to be looking at something on the ceiling. I see something there, too.”
D. Continue the interview without comment on the client’s behavior.
B. Ask the client, “Are you seeing something on the ceiling?”
A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “I can promote my client’s sense of control by establishing a schedule.
“B. “I should encourage clients who have a schizoid personality disorder to increase socialization
C. “I should practice limit-setting to help prevent client manipulation.”
D. “I should implement assertiveness training with clients who have antisocial personality disorder.”
C. “I should practice limit-setting to help prevent client manipulation.”
A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?
A. “I’m scared that you’re going to leave me.
B. “I’ll go to group therapy if you’ll let me smoke.
C. “I need to feel that everyone admires me.
D. “I sometimes feel better if I cut myself.”
A. “I’m scared that you’re going to leave me.
A nurse is caring for a client who has borderline personality disorder. The client says, “The nurse on the evening shift is always nice! You are the meanest nurse ever!” The nurse should recognize the client’s statement as an example of which of the following defense mechanisms?
A. Regression
B. Splitting
C. Undoing
D. Identification
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Demonstrates extreme anxiety when placed in a social situation
B. Has difficulty making even simple decisions
C. Attempts to convince other clients to give him their belongings
D. Becomes agitated if his personal area is not neat and orderly
E. Blames others for his past and current problems
A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (Select all that apply)
A. Difficulty in getting along with other members of a group
B. Belief in the ability to become invisible during times of stress
C. Display of defense mechanisms when routines are changed
D. Claiming to be more important than other persons
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
A nurse is caring for a client who has early stage Alzheimer’s disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication?
A. “You should avoid taking over-the-counter acetaminophen while on donepezil.”
B. “You can expect the progression of cognitive decline to slow with donepezil.”
C. “You will be screened for underlying kidney disease prior to starting donepezil.”
D. “You should stop taking donepezil if you experience nausea or diarrhea.”
B. “You can expect the progression of cognitive decline to slow with donepezil.”
A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, “I have to get home.” Which of the following statements should the nurse make?
A. “You have forgotten that this is your home.
B. “You cannot go outside without a staff member.”
C. “Why would you want to leave? Aren’t you happy with your care?”
D. “I am your nurse. Let’s walk together to your room.”
D. “I am your nurse. Let’s walk together to your room.”
A home health nurse is making a visit to a client who has Alzheimer’s disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client’s risk for injury? (Select all that apply)
A. Install childproof door locks.
B. Place rugs over electrical cords.
C. Mark cleaning supplies with colored tape
D. Place the client’s mattress on the floor.
E. Install light fixtures above stairs.
A nurse is making a home visit to a client who is in the late stage of Alzheimer’s disease. The client’s partner, who is the primary caregiver, wishes to discuss concerns about the client’s nutrition and the stress of providing care. Which of the following actions should the nurse take?
A. Verify that a current power of attorney document is on file.
B. Instruct the client’s partner to offer finger foods to increase oral intake.
C. Provide information on resources for respite care.
D. Schedules the client for placement of an enteral feeding tube.
C. Provide information on resources for respite care.
A nurse is performing an admission assessment for a client who has delirium related to an acute UTI. Which of the following findings should the nurse expect? (Select all that apply)
A. History of gradual memory loss
B. Family report of personality changes
C. Hallucinations
D. Unaltered level of consciousness
E. Restlessness
B. Family report of personality changes
C. Hallucinations
E. Restlessness
A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation?
A. Older adults require higher doses of a substance to achieve a desired effect.
B. Older adults commonly use rationalization to cope with a substance use disorder.
C. Older adults are at an increased risk for substance use following retirement.
D. Older adults develop substance use to mask manifestations of dementia.
C. Older adults are at an increased risk for substance use following retirement.
B. Fine tremors of both hands
D. Vomiting
E. Restlessness
A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority?
A. Orient the client frequently to time, place, and person.
B. Offer fluids and nourishing diet as tolerated.
C. Implement seizure precautions.
D. Encourage participation in group therapy sessions.
C. Implement seizure precautions.
A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol?
A. Chlordiazepoxide
B. Bupropion
C. Disulfiram
D. Carbamazepine
A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicate an understanding of the teaching? (Select all that apply)
A. “We need to understand that she is responsible for her disorder.”
B. “Eliminating any codependent behavior will promote her recovery.”
C. “She should participate in an Al-Anon group to help her recover.”
D. “The primary goal of her treatment is abstinence from substance use.”
E. “She needs to discuss her feelings about substance use to help her recover.”
A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (Select all that apply)
A. “What is your relationship like with your family.
B. “Why do you want to lose weight?
C. “Would you describe your current eating habits?
D. “At what weight do you believe you will look better?
E. “Can you discuss your feelings about your appearance?”
A nurse is caring for an adolescent client who has anorexia nervosa with rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion catastrophizing?
A. “Life isn’t worth living if I gain weight.
B. “Don’t pretend like you don’t know how fat I am.
C. “If I could be skinny, I know I’d be popular.
D. “When I look in the mirror, I see myself as obese.”
A.” Life isn’t worth living if I gain weight.”
B. Hypokalemia
D. Slightly elevated body weight
A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions should the nurse include in the client’s plan of care?
A. Allow the client to select preferred meal times.
B. Establish consequences for purging behavior.
C. Provide the client with a high-fat diet at the start of treatment.
D. Implement one-to-one observation during meal times.
D. Implement one-to-one observation during meal times.
A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following responses should the nurse make?
A. “Many clients are concerned about their weight. However the dietitian will ensure that you don’t get too many calories in your diet.”
B. “Instead of worrying about your weight, try to focus on other problems at this time.”
C. “I understand you have concerns about your weight, but first, let’s talk about your recent accomplishments.”
D. “You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you.”
B. Anxiety disorder
C. Female gender
A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client as risk for conversion disorder?
A. Death of a child 2 months ago
B. Recent weight loss of 30 lb
C. Retirement 1 year ago
D. History of migraine headaches
A. Death of a child 2 months ago
A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include?
A. Encourage the client to spend time alone in his room
B. Monitor the client for self-harm once per day
C. Allow the client unlimited time to discuss physical manifestations
D. Discuss alternative coping strategies with the client
D. Discuss alternative coping strategies with the client
A nurse is counseling a client who has factitious disorder imposed on another. Which of the following client statements should the nurse expect?
A. “I had to pretend I was injured in order to get disability benefits.
B. “I know that my abdominal pain is caused by a malignant tumor.
C. “I needed to make my son sick so that someone else would take care of him for a while.
D. “I became deaf when I heard that my husband was having an affair with my best friend.”
C. I needed to make my son sick so that someone else would take care of him for a while
A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following information should the nurse provide?
A. Three to six weeks of treatment is required to achieve therapeutic benefit
B. Combining alcohol with diazepam will produce a paradoxical response
C. Diazepam has a lower risk for dependence than other antianxiety medications
D. Report confusion as a potential indication of toxicity
D. Report confusion as a potential indication of toxicity
A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse’s priority?
A. Administer flumazenil
B. Identify the client’s level of orientation
C. Infuse IV fluids
D. Prepare the client for gastric lavage
B. Identify the client’s level of orientation
A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication?
A. “I will take the medication at bedtime.
B. “I will follow a low-sodium diet while taking this medication.
C. “I will need to discontinue this medication slowly.
D. “I will be at risk for weight loss with long term use of this medication.”
C. “I will need to discontinue this medication slowly.
B. Hallucinations
D. Diaphoresis
E. Agitation
A nurse is caring for a client who takes paroxetine to treat PTSD. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client’s bruxism? (Select all that apply)
A. Concurrent administration of buspirone
B. Administration of a different SSRI
C. Use of a mouth guard.
D. Changing to a different class of antianxiety medication
E. Increasing the dose of paroxetine
A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
A. “While taking this medication, I’ll need to stay out of the sun to avoid a skin rash.
B. “I may feel drowsy for a few weeks after starting this medication.”
C. “I cannot eat my favorite pizza with pepperoni while taking this medication.”
D. “This medication will help me lose the weight that I have gained over the last year.”
B. “I may feel drowsy for a few weeks after starting this medication.”
A. Elevated blood glucose level
D. Headache
A nurse is review the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider?
A. The client has a family history of SAD.
B. The client currently smokes 1.5 packs of cigarettes per day.
C. The client had a motor vehicle crash last year and sustained a head injury.
D. The client has a BMI of 25 and has gained 10 lb over the last year.
C. The client had a motor vehicle crash last year and sustained a head injury.
A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (Select all that apply)
A. Void just before taking the medication
B. Increase the dietary intake of potassium
C. Wear sunglasses when outside
D. Change positions slowly when getting up
E. Chew sugarless gum
A. Void just before taking the medication
C. Wear sunglasses when outside
E. Chew sugarless gum
A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?
A. “This medication increases the release of serotonin and norepinephrine.”
B. “I will need to monitor the client for hyponatremia while taking this medication.”
C. “This medication is contraindicated for clients who have an eating disorder.”
D. “Sexual dysfunction is a common adverse effect of this medication.”
A. “This medication increase the release of serotonin and norepinephrine”
A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make?
A. “That is a good choice. Ibuprofen does not interact with lithium.”
B. “Regular aspirin would be a better choice than ibuprofen.”
C. “Lithium decreases the effectiveness of ibuprofen.”
D. “The ibuprofen will make your lithium level fall too low.”
B. “Regular aspirin would be better choice than ibuprofen.”
A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client’s lithium blood level 1.2 mEq/L. Which of the following actions should the nurse take?”
A. Administer the next dose of lithium carbonate as scheduled.
B. Prepare for administration of aminophylline.
C. Notify the provider for a possible increase in the dosage of lithium carbonate.D
. Request a stat repeat of the client’s lithium blood level.
A. Administer the next dose of lithium carbonate as scheduled.
A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client’s adult daughter, which of the following statements is the priority to report to the provider?
A. “My mother has diabetes that is controlled by her diet.”
B. “My mother recently completed a course of prednisone for acute bronchitis.”
C. “My mother received her flu vaccine last month.”
D. “My mother is currently on furosemide for her congestive heart failure.”
D. “My mother is currently on furosemide for her congestive heart failure.”
A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change in which of the following medications? (Select all that apply)
A. Olanzapine
B. Quetiapine
C. Aripiprazole
D. Clozapine
E. Asenapine
C. Apripiprazole
D. Clozapine
E. Asenapine
A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first generation antipsychotics? (Select all that apply)
A. Auditory hallucinations
B. Withdrawal from social situations
C. Delusions of grandeur
D. Severe agitation
E. Anhedonia
A. Auditory hallucinations
C. Delusions of grandeur
D. Severe agitation
C. Involuntary arm movements
E. Continual pacing
A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates an understanding of the teaching?
A. I will be able to stop taking this medication as soon as I feel better B. If I feel drowsy during the day, I will stop taking the medication as soon as I feel better
C. I will be careful not to gain too much weight while taking this medication
D. this medication is highly addictive and must be withdrawn slowly
C. I will be careful not to gain too much weight while taking this medication
A. Seizures
C.Photophobia
D. Dry mouth
E. Irregular pulse
A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide?
A. Eat a diet high in fiber
B. Check temperature daily
C. Take medication first thing in the morning before eating
D. Add extra calories to the diet as between-meal snacks
A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication?
A. Apply the patch once daily at bedtime
B. Place the patch carefully in a trash can after removal
C. Apply the transdermal patch to the anterior waist area
D. Remove the patch each day after 9 hr
D. Remove the patch each day after 9 hr
A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (Select all that apply)
A. An adverse effect of this medication is CNS depression
B. Administer the medication in the morning
C. Monitor for weight loss while taking this medication
D. Therapeutic effects of this medication will take 1-3 weeks to fully develop
E. This medication blocks the synaptic reuptake of serotonin in the brain.
A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching?
A. “This medication will help prevent seizures during alcohol withdrawal.”
B. “Taking this medication will decrease your cravings for alcohol.”
C. “This medication maintains your blood pressure at a normal level during alcohol withdrawal.”
D. “Taking this medication will improve your ability to maintain abstinence from alcohol.”
A.” This medication will help prevent seizures during alcohol withdrawal.”
C. Disulfiram
D. Naltrexone
E. Acamprosate
A nurse is evaluating a client’s understanding of a new prescription for clonidine for the treatment or opioid use disorder. Which of the following statements by the client indicates an understanding of the teaching?
A. “Taking this medication will help reduce my craving for heroin.”
B. “While taking this medication, I should keep a pack of sugarless gum.
“C. “I can expect some diarrhea from taking this medicine.
“D. “Each dose of this medication should be placed under my tongue to dissolve.”
C. “I can expect some diarrhea from taking this medicine”.
A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply)
A. “Methadone is a replacement for physical dependence to opioids.”
B. “Methadone reduces the unpleasant effects associated with abstinence syndrome.”
C. “Methadone can be used during opioid withdrawal and to maintain abstinence.”
D. “Methadone increases the risk for acetaldehyde syndrome.”
E. “Methadone must be prescribed and dispensed by an approved treatment center.”
A. “Methadone is a replacement for physical dependence to opioids.”
A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse include in the teaching?
A. Chew the gm for no more than 10 min.
B. Rinse out the mouth immediately before chewing the gum.
C. Avoid eating 15 min prior to chewing the gum.
D. Use of the gum is limited to 90 days.
C.” Avoid eating 15 min prior to chewing the gum”
A nurse is caring for a client following the loss of her partner due to a terminal illness. Identify the sequence of Engel’s five stages of grief that the nurse should expect the client to experience. (Select the stages of grief in the order of occurrence. All steps must be used.)
A. Developing awareness
B. Restitution
C. Shock and disbelief
D. Recovery
E. Resolution of the loss
C. Shock and disbelief
A. Developing awareness
B. Restitution
E. Resolution of the loss
D. Recovery
B. Denial
C. Bargaining
D. Anger
E. Depression
A. Interpersonal relationships
B. Culture
D. Religious beliefs
E. Prior experience with loss
A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply)
A. “I may experience feelings of resentment.”
B. “I will probably withdraw from others.”
C. “I can expect to experience changes in sleep.”
D. “It is possible that I will experience suicidal thoughts.”
E. “It is expected that I will have a loss of self-esteem.”
A nurse is caring for a client who lost his mother to cancer last month. The client states, “I’d still have my mother if the doctor would have diagnosed her sooner.” Which of the following responses should the nurse make?
A. “You sound angry. Anger is a normal feeling associated with loss.”
B. “I think you would feel better if you talked about your feelings with a support group.”
C. “I understand just how you feel. I felt the same when my mother died.”
D. “Do other members of your family also feel this way?”
A. “You sound angry. Anger is a normal feeling associated with loss.”
A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply)
A. Allow the child to choose consequences for negative behavior
B. Use role-playing to act out unacceptable behavior
C. Develop a reward system for acceptable behavior
D. Encourage the child to participate in school sports
E. Be consistent when addressing unacceptable behavior
B. Substance use
D. Irritability
E. Aggressiveness
A. Bullying of others
B. Threats of suicide
C. Law-breaking activities
A nurse in a pediatric clinic is caring for a preschool-age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching?
A. “Behaviors associated with ADHD are present prior to age 3.”
B. “This disorder is characterized by argumentativeness.”
C. “Below-average intellectual functioning is associated with ADHD.”
D. “Because of this disorder, your child is at increased risk for injury.”
“Because of this disorder, your child is at increased risk for injury.”
A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (Select all that apply)
A. “My family will be better off if I’m dead.”
B. “The stress in my life is too much to handle.”
C. “I wish my life was over.”
D. “I don’t feel like I can ever be happy again.”
E. “If I kill myself then my problems will go away.
A nurse is caring for a client who states, “I plan to commit suicide.” Which of the following assessments should the nurse identify as the priority?
A. Client’s educational and economic background
B. Lethality of the method and availability of means
C. Quality of the client’s social support
D. Client’s insight into the reasons for the decision
E. The greatest risk to the client is self-harm as a result of carrying out a suicide plan.
B. Lethality of the method and availability of means
A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (Select all that apply)
A. Conducting a suicide risk screening on all new clients
B. Creating a support group for family members of clients who completed suicide
C. Educating high school teens about suicide prevention
D. Initiating one-on-one observation for a client who has suicidal ideation
E. Teaching middle-school educators about warning indicators of suicide
A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?
A. Assign the client to a private room
B. Document the client’s behavior every hour
C. Allow the client to keep perfume in her room
D. Ensure that the client swallows medication
D. Ensure that the client swallows medication
A nurse is conducting a class for a group of newly licensed nurses on caring for clients who at risk for suicide. Which of the following information should the nurse include in the teaching?
A. A client’s verbal threat of suicide is attention-seeking behavior
B. Interventions are ineffective for clients who really want to commit suicide
C. Using the term suicide increases the client’s risk for a suicide attempt
D. A no-suicide contract decreases the client’s risk for a suicide attempt
D. A no-suicide contract decreases the client’s risk for a suicide attempt
A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication?
A. “I wish you could not make me angry.”
B. “I feel angry when you leave me.”
C. “It makes me angry when you interrupt me.”
D. “You’d better listen to me.”
D. “You’d better listen to me.”
A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?
A. Insist that the client stop yelling
B. Request that other staff members remain close by
C. Move as close to the client as possible
D. Walk away from the client
B. Request that other staff members remain close by
B. Defensive responses to questions
D. Rapid breathing
E. Facial grimacing
F. Agitation
A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action?
A. Encourage the client to express her feelings
B. Maintain eye contact with the client
C. Move the client away from others
D. Tell the client that the behavior is not acceptable
C. Move the client away from others
A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client?
A. “Stop screaming, and walk with me outside.”
B. “Why are you so angry and screaming at everyone?”
C. “You will not get your way by screaming.”
D. “What was going through your mind when you started screaming?”
A. “Stop screaming, and walk with me outside.”
A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of the teaching?
A. “Children older than 3 are at greater risk for abuse.”
B. “Substance use disorder does not increase the risk for violence.”
C. “Entering an intimate relationship increases the risk for violence.”
D. “Pregnancy increases the risk for violence toward the intimate partner.”
D. “Pregnancy increases the risk for violence toward the intimate partner.”
B. Respiratory distress
C. Retinal hemorrhage
D. Altered LOC
E. Increase in head circumference
A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible abuse (Select all that apply)?
A. Abrasions on knees
B. Round burn marks on forearms
C. Mismatched clothing
D. Abdominal rebound tenderness
E. Areas of ecchymosis on torso
B. Round burn marks on forearms
E. Areas of ecchymosis on torso
A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?
A. Refusing to pay bills for a dependent, even when funds are available, is neglect.
B. Intentionally causing an older adult to fall is an example of physical violence.
C. Striking an intimate partner is an example of sexual violence.
D. Failure to provide a stimulating environment for normal development is emotional abuse.
B. Intentionally causing an older adult to fall is an example of physical violence.
A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority?
A. Advise the client about the location of women’s shelters
B. Encourage the client to participate in a support group for survivors of abuse
C. Implement case management to coordinate community and social services
D. Educate the client about the use of stress management techniques
A. Advise the client about the location of women’s shelters
A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction? (Select all that apply)
A. Sudden development of phobias
B. Development of substance use disorder
C. Increased level of anxiety during interview
D. Reactivation of a prior physical disorder
E. Unwillingness to discuss the sexual assault
A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply)
A. Genitourinary soreness
B. Difficulties with low self-esteem
C. Sleep disturbances
D. Emotional outburst
E. Difficulty making decisions
D. Emotional outburst
E. Difficulty making decisions
A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “I will administer prophylactic treatment for sexually transmitted infections.”
B. “I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence.”
C. “I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder.”
D. “I should use narrative documentation when documenting subjective data.”
A. “I will administer prophylactic treatment for sexually transmitted infections.”
A nurse is caring for a client who was recently raped. The client states, “I never should have been out on the street alone at night.” Which of the following responses should the nurse make?
A. “Your actions had nothing to do with what happened.”
B. “You should focus on recovery rather than blaming yourself for what happened.”
C. “You believe this wouldn’t have happened if you hadn’t been out alone?”
D. “Why do you feel that you should not have been alone on the street at night?”
C. “You believe this wouldn’t have happened if you hadn’t been out alone?”
A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?
A. “Rape is a crime of passion.”
B. “Acquaintance rape often involves alcohol.”
C. “Young adults are the typical victims of sexual assault.”
D. “The majority of rapists are unknown to the victims.”
B. “Acquaintance rape often involves alcohol.”
A nurse is planning overall strategies to address problems for a client who
has a borderline personality disorder. Which of the following strategies is the
priority for the nurse to incorporate into the plan of care?
a. discuss the appropriate use of assertive behavior with the client
b. encourage the client to attend weekly support group meetings
c. assist the client to maintain awareness of her thoughts and feelings
d. implement measures to prevent intentional self-inflicted injury
d. implement measures to prevent intentional self-inflicted injury
A nurse is admitting a client who has a generalized anxiety disorder. Which of the following actions should the nurse plan to take first?
a. Provide the client with a quiet environment
b. Determine how the client handles stress.
c. Teach the client to use guided imagery.
d. Ask the client to identify her strengths
a. Provide the client with a quiet environment
A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following should the nurse report to the provider?
a. States that he hasn’t bathed in 2 days
b. Reports eating twice in the past two weeks.
c. Makes inappropriate sexual comments.
d. Speaks in rhyming sentences.
b. Reports eating twice in the past two weeks.
A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
a. Encourage the client to join group activities
b. Dim the lights in the client’s room
c. Provide detailed explanations to the client
d. Administer methylphenidate
b. Dim the lights in the client’s room
c. Identify prior coping skills
An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states “Im so worried that my mother is depressed” which of the following responses should the nurse make?
a. Everyone gets depressed from time to time.
b. You shouldn’t worry about this because the depressive disorder is easily treated.
c. Older adults are usually diagnosed with the depressive disorder as they age.
d. Tell me the reasons you think your mother is depressed.
d. Tell me the reasons you think your mother is depressed.
A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan care?
a. Meets own needs without manipulating others.
b. Initiates social interactions with caregivers.
c. Changes behavior as a result of peer pressure.
d. Acknowledges his delusions are not real.
b. Initiates social interactions with caregivers.
A nurse is providing behavior therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
a. Snap a rubber band on your wrist when you think about checking the locks.
b. Ask a family member to check the locks for you at night.
c. Focus on abdominal breathing whenever you go to check the locks.
d. Keep a journal of how often you check the locks each night.
a. Snap a rubber band on your wrist when you think about checking the locks.
A nurse is caring for a client who is starting treatment for substance use disorder. Which of the following actions indicates the nurse is practicing the ethical principle of nonmaleficence?
a. Provide the client with quality care regardless of their ability to pay for treatment.
b. Educating the client about legal rights concerning treatment.
c. Withholding the prescribed medication that is causing adverse effects for the client.
d. Being truthful with the client about the manifestations of withdrawal.
c. Withholding the prescribed medication that is causing adverse effects for the client.
A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from other clients. Which of the following techniques should the nurse use?
a. Crisis intervention to decrease anxiety.
b. Aversion therapy to provide distraction
c. Positive reinforcement to increase desired behavior.
d. Systematic desensitization to extinguish the behavior.
c. Positive reinforcement to increase desired behavior.
d. Have the client breathe into a paper bag.
A nurse is caring for a client in a mental health facility. The client is agitated and threatens to harm herself and others. Which of the following is the priority intervention?
a. Place the client in restraints
b. Administer an anti-anxiety medication to the client
c. Put the client in seclusion
d. Set limits on the client’s behavior
d. Set limits on the client’s behavior
18) A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take?
a. Ask the clients family to encourage the client to receive ECT
b. Inform the client that ECT does not require a consent.
c. Document the client’s refusal of the treatment in the medical record.
d. Tell the client he cannot refuse the treatment because he was
involuntarily committed.
c. Document the client’s refusal of the treatment in the medical record.
A nurse in the emergency department is caring for a client who reports feeling sad, worthless, and hopeless 9 months after the death of her son. Which of the following actions should the nurse take first?
a. Request a mental health consult for the client.
b. Ask the client if she has thought about harming herself.
c. Encourage the client to attend a grief support group.
d. Discuss the clients coping skills.
c. Encourage the client to attend a grief support group.
A nurse is caring for a client who has borderline personality disorder and has been engaging in self- mutilation. The nurse should encourage the client to participate in which of the following groups.
a. Dual diagnosis treatment group
b. Dialectical Behavior treatment group
c. Desensitization therapy
b. Dialectical Behavior treatment group
The nurse is reviewing the medication administration record of a client who has schizophrenia. The nurse should plan to initiate the Abnormal Involuntary Movement Scale to monitor for adverse effects of which of the following medications.?
a. Amantadine
b. Diphenhydramine
c. Benztropine
d. Haloperidol
A nurse is counseling a client following the death of a client’s partner 8 months ago. Which of the following client statements indicates maladaptive grieving?
a. I am so sorry for the times I was angry with my partner.
b. I find myself thinking about my partner often.
c. I still don’t feel up to returning to work.
d. I like looking at his personal items in the closet.
c. I still don’t feel up to returning to work.
A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?
a. The client will report a decrease in hallucinations.
b. The client will communicate needs
c. The client will verbalize improved mood
d. The client will attend to personal hygiene.
c. The client will verbalize improved mood
A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states “I can’t stand to be touched by another person.” Which of the following responses should the nurse make?
a. Why don’t you like to be touched by others
b. Don’t worry about it. Your anxiety will lessen once the massage begins.
C. I will tell your provider you would like a treatment other than a massage.
d. I will request that the massage therapist wear gloves during your treatment.
C. I will tell your provider you would like a treatment other than a massage.
A nurse is creating a plan of care for a client who has a major depressive disorder. Which of the following interventions should the nurse include in the plan?
a. Encourage physical activity for the client during the day
b. Discourage the client from expressing feelings of anger
c. Keep a bright light on in the client’s room at night.
d. Identify and schedule alternative group activities for the client.
a. Encourage physical activity for the client during the day
A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role as the monopolizer?
a. The mother who expresses hostility toward her spouse.
b. The adolescent son who refuses to share personal feelings.
c. The father who intervenes whenever the siblings argue.
d. The adolescent daughter who attempts to dominate the conversation.
d. The adolescent daughter who attempts to dominate the conversation.
A nurse is developing a teaching plan for the family of an older adult client who is to receive transcranial magnetic stimulation. Which of the following information should the nurse include in the teaching plan?
a. The client might have a headache after treatment.
b. The client will experience seizure during treatment.
c. The client will require intubation after treatment.
d. The client is at risk for aspiration during treatment.
a. The client might have a headache after treatment.
A nurse is providing teaching about disulfiram to a client who has a history of alcohol use. Which of the following instructions should the nurse include in the teaching? (Select all that apply)
a. “You will need to take the medication once daily”
b. “you will receive treatment in an inpatient setting”
c. “You should avoid using mouthwash that contains alcohol”
d. “you should avoid drinking carbonated beverages while taking the medication”
e. “you can expect to develop a physical dependence on the medication”
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following actions should the nurse take?
a. Avoid power struggles by remaining neutral
b. Allow the client to set limits for his behavior
c. Provide in-depth explanation of nursing expectations
d. Encourage the client to participate in group activities
a. Avoid power struggles by remaining neutral
A nurse is providing discharge teaching about manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching?
a. The client exhibits an inflated sense of self
b. The client develops an inability to concentrate
c. The client increases participation in social activities
d. The client begins sleeping more than usual
b. The client develops an inability to concentrate
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?
a. The client is unable to recognize objects.
b. The client manifestations developed suddenly
c. The client has a flat affect
d. The client’s speech is slow and repetitious
b. The client manifestations developed suddenly
A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?
a. ” You know that’s not true, because it is against the law for others to read your mail”
b. “All of your letters come sealed, so that seems unlikely”
c. “It must be frightened to think that someone is reading your mail”
d. “why do you think the government wants to read your mail?”
c. “It must be frightened to think that someone is reading your mail”
A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?
a. Talking negatively about other staff members
b. Expressing frustration regarding unit rules
c. Reacting to the nurse as though she were his mother
d. Refusing to participate in group activities
c. Reacting to the nurse as though she were his mother
A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?
a. Request that the client’s guardian sign the consent
b. Ask the charge nurse to obtain informed consent
c. Contact the facility social worker to obtain the consent
d. Explain implied consent to the client’s family
a. Request that the client’s guardian sign the consent
A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching?
a. “Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD”
b. “Talking about the traumatic experience is recommended”
c. “Response prevention is an effective treatment for PTSD”
d. “You should try to limit the number of hours that you sleep each day”
b. “Talking about the traumatic experience is recommended”
A nurse is caring for a client who has schizophrenia and displays severe negative symptoms of the disorder. Which of the following actions should the nurse take?
a. Manage the client’s loud, rambling, and incoherent communication patterns
b. Direct the client to perform her own daily hygiene and grooming tasks
c. Assist the client to identify somatic and thought-broadcasting delusions
d. Use medication to decrease frequency of auditory and visual hallucination.
b. Direct the client to perform her own daily hygiene and grooming tasks
A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase?
a. Inform the client about confidentiality rights
b. Establish boundaries between the nurse and the client
c. Set short and long-term objectives for the future
d. Evaluate progress toward predetermined goals
d. Evaluate progress toward predetermined goals
A nurse in a mental health facility is making plans for a client’s discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement?
a. Clinical nurse specialist
b. Recreational therapist
c. Occupational therapist
d. Social worker
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanism is the client demonstrating?
a. Denial
b. Displacement
c. Compensation
d. Rationalization
A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
a. “The client is just like my brother who finally overcame his habit”
b. “The client needs to accept responsibility for his substance use”
c. “The client generally shares his feelings during group therapy session”
d. “The client asked me to go on a date with him, but I refuse”
a. “The client is just like my brother who finally overcame his habit”
A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
a. Establish a rapport to foster trust
b. Implement continuous one-to-one observation
c. Ask the client to sign a no-suicide contract
d. Encourage the client to participate in group therapy
b. Implement continuous one-to-one observation
A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanism. Which of the following examples should the nurse include in the teaching?
a. A student who is upset with her teacher writes a story about an excellent student
b. A school-age child whose mother died 2 years ago talks about her in present tense.
c. A woman who has health concern postpones a medical appointment until after a vacation.
d. An adult who was sexually abused as a child is unable to remember the incident
a. A student who is upset with her teacher writes a story about an excellent student
A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder. Which of the following outcomes should the nurse include in the care plan?
a. The client recognizes the importance of others
b. The client conforms to social norms regarding clothing choices
c. The client reduces self-dramatization
d. The client treats others with respect
d. The client treats others with respect
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
a. Negotiate with the client how much weight she should gain each week.
b. Decrease the client’s daily intake of fiber
c. Weight the client weekly for the first month
d. Notify the client about designated time for meals
d. Notify the client about designated time for meals
A client is fearful of driving and enters a behavioral therapy program to help him overcome his anxiety. Using systematic desensitization, he is able to drive down a familiar street without experience a panic attack. The nurse should recognize that to continue positive results, the client should participate in which of the following?
a. Therapist modeling
b. Positive reinforcement
c. Frequent practice
d. Biofeedback
A nurse in the emergency department is counseling a client who reports experiencing intimate partner violence. Which of the following actions should the nurse take?
a. Request permission from the client to take photographs of the injuries
b. Offer to help the client escape from the partner the next time violence occurs
c. Determine what the client did to trigger the violent incident
d. Tell the client that staying with the partner shows a lack of judgment
a. Request permission from the client to take photographs of the injuries
A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?
a. Avoid asking direct questions about the client’s experience
b. Convey sympathy for the client’s experience
c. Tell her client her experience is not real
d. Focus the client on reality-based activities
d. Focus the client on reality-based activities
57) A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an inappropriate comment. Which of the following responses should the nurse make?
a. “I think you should ignore the comment”
b. “You sound upset about today’s session”
c. “Why do you think that he said that to you?”
d. “I agree that the comment was inappropriate”
b. “You sound upset about today’s session”
A nurse is teaching a client who has bipolar disorder and a new prescription for lithium carbonate. Which of the following statements by the client indicates an understanding of the teaching?
a. “I should drink at least 6 liters of water per day”
b. “I should be on a low-sodium diet”
c. “I will call my doctor if I have diarrhea”
d. “I will see my doctor to check my lithium levels annually”
c. “I will call my doctor if I have diarrhea”
A nurse in an acute care mental health facility is planning discharge care for a client who sustained a traumatic brain injury. For which of the following needs should the nurse collaborate with a clinical psychologist?
a. The client needs a prescription for medication to promote nighttime sleep while in the facility
b. The client needs to find a place to live after discharge
c. The client needs to begin a group therapy program prior to discharge
d. The client needs to relearn how to perform skills that require fine motor coordination 61.
c. The client needs to begin a group therapy program prior to discharge
A nurse is teaching the caregiver of a client who has advanced Alzheimer’s disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?
a. I will ensure the bedroom is dark while he is sleeping at night
b. I will place a sliding bolt lock just above the doorknob
c. I will notify law enforcement within 2 hours if he cannot be found
d. I will give his most recent photo to the police
b. I will place a sliding bolt lock just above the doorknob
A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment finding in the client’s history should the nurse report to the provider?
a. Hepatitis B Infection
b. Hypothyroidism
c. Knee arthroplasty 1 month ago
d. Recent head injury
A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client?
a. help the client focus on a wide variety of topics regarding the crisis
b. identify the client’s usual coping style
c. tell the client that his life will soon return to normal
d. encourage the client to display anger toward the cause of the crisis
b. identify the client’s usual coping style
A nurse is providing teaching to a client who has depressive disorder and a new prescription for doxepin. Which of the following instructions should the nurse include in the teaching?
a. sit on the side of the bed for a few minutes before standing
b. decrease the prescribed dose by half when mood improves
c. avoid over the counter magnesium when taking this medication
d. eat a snack before going to bed
a. sit on the side of the bed for a few minutes before standing
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan?
a. give detailed instructions for completion of self-care activities
b. confront the client when he exhibits inappropriate behavior
c. provide finger foods to enhance caloric intake
d. remove clocks from the client’s room
c. provide finger foods to enhance caloric intake
A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should the nurse include in the teaching?
a. “You should discontinue this medication if you develop muscle rigidity.”
b. “You will experience weight loss while taking this medication.”
c. “You will notice your symptoms improve within 24 hours of taking
this medication.”
d. “You should increase your consumption of complex carbohydrates.”
a. “You should discontinue this medication if you develop muscle rigidity.”
A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicated an understanding of the teaching?
a. “I will provide my mother with detailed instructions about how to perform self-care.”
b. “I will limit my mother’s clothing choices when she is getting dressed.”
c. “I will wake my mother up a couple of times in the night to check on her.”
d. “I will discourage my mother from talking about her physical complaints.”
b. “I will limit my mother’s clothing choices when she is getting dressed.”
A nurse is planning care for a client who has anorexia nervosa and is admitted to an inpatient eating disorder unit. Which of the following is an appropriate intervention?
a. Use systematic desensitization to address the client’s fears regarding weight gain.
b. Allow the client to select mealtimes.
c. Initiate a relationship built on trust with the client.
d. Negotiate with the client the opportunity to reweigh.
c. Initiate a relationship built on trust with the client.
A nurse in a mental health facility is caring for a client. Which of the following actions should the nurse take during the working phase of the nurse-client relationship?
a. Summarize goals and objectives.
b. Address confidentiality.
c. Promote problem-solving skills.
d. Establish a participation contract.
c. Promote problem-solving skills.
Identify professional boundaries during the initial interaction
Incorporating the attributes or feelings of another person into oneself
Lorazepam; this will maintain vitals, prevent seizures, and delirium tremens
Observe the client swallow medications
Medication that is given to patients who are withdrawing from opioids
Medication that is administered during alcohol withdrawl
Chlordiazepoxide- helps prevent seizures and delirium tremens
Medication that is administered during an opioid/narcotic overdose
“Yesterday my partner put a jacket on upside down”
Dependent personality disorder
LFT’s— due to the risk of hepatotoxicity
Early signs of lithium toxicity
Levels between 1.0-1.5 = Fine tremors, nausea, vomiting, diarrhea, muscle weakness, lethargy
Late signs of lithium toxicity
Insomnia, restlessness, elevated temperature, muscle tremors, tachycardia
The client reports sleeping 2-3 hours per night— the greatest risk is injury from exhaustion
Donepezil can improve cognitive functioning during the earlier stages of the disease.
The inability to recall important personal information—response to a traumatic or stressful event.
A patient feeling that their surroundings are unreal or distant.
Smoking cessation, S.A.D., and depression
What can increase your chances of lithium toxicity?
Taking furosemide and lithium together
What increases your chances for a HTN crisis?
Taking phenelazine and Tyra mine rich foods together. An example is smoked sausage.
What are positive symptoms of schizophrenia
Beta blockers should not be used in patients with what health care issue?
Adverse effect of taking chlorpromazine
What medication increases your risk for seizures?
What 2 medications when taken together can increase the risk of serotonin syndrome?
What medication increases a patients risk for orthostatic hypotension?
Symptoms of neuroleptic malignant syndrome
muscle rigidity, hyperpyrexia, fluctuations in blood pressure, and altered level of consciousness.
Provide small frequent meals for patients with binge eating disorders
Provide meals at scheduled time for patients with anorexia Nervosa
What medication does someone take when Alzheimer’s becomes severe?
When would you withold lithium from a patient?
When a patient reports nausea with frequent episodes of vomiting.
What meds can be prescribed in patients who are withdrawing from alcohol?
What is an A/E of carbamazepine?
Medication that reduces the urge to smoke
Telling a patient that they will get a shot if they remain agitated.
When taking Clozapine check WBC weekly x 6 months
If a patient states their skin is itching from their nicotine patch what do you do as the nurse?
A patient with schizophrenia states “my doctor is trying to kill me” how do you respond?
“It must be frightening to feel that your doctor is trying to kill you”
negative symptoms of schizophrenia
Do not use more than 20 per day
A nurse is assisting with the planning of a therapeutic support group for individuals who have bulimia nervosa. Which of the following tasks should the nurse include during the orientation phase of group development?
A. determine the rules that the group will follow
B. address disagreements among group members
C. help clients work through the grief response
D. transition from the role of leader to facilitator
A nurse is providing support for a client who is grieving the loss of her mother who died from Alzeimer’s disease. Which of the following statements should the nurse offer?
A. “I know how you must be feeling. I recently lost my father.”
B. “Dealing with your mother’s death must be difficult for you.”
C. “Knowing your mother is in a better place provides you with some comfort.”
D. “I want you to let me know what I can do to help you cope with your mother’s death.”
A nurse on a mental health unit is caring for a client who is displaying signs of anger. Which of the following pieces of information about the client is the strongest indicator that the client might become aggressive?
A. The client has marginal coping skills
B. The client has a history of violence
C. The client feels powerless after being hospitalized
D. The client blames others for her problems
A nurse is reinforcing teaching with the caregiver of a client who has dementia. Which of the following instructions should the nurse include in the teaching?
A. Offer the client a list of activities to choose from
B. Offer finger foods to the client
C. Discourage naps throughout the day
D. Turn on the television when the client is in the room
A nurse is contributing to the plan of care for a client with bipolar disorder who has acute mania. Which of the following interventions should the nurse recommend including in the plan?
A. Provide the client with a low-calorie, low-fat diet
B. Encourage the client to have frequent rest periods
C. Escort the client to daily group therapy
D. Limit the client’s intake of caffeinated beverages to 12 oz per day
A nurse is reviewing the plan of care for a client who has bipolar disorder. Which of the following is an effect of using cognitive behavioral therapy (CBT) for a client who has bipolar disorder?
A. Prevents the need for mood-stabilizing medications
B. Helps the client deal with distorted thought processes
C. Aids in communication among family members
D. Replaces the need for lifestyle interventions
Helps the client deal with distorted thought processes
*CBT assists the client with recognizing distorted thought processes that are maladaptive with regards to recovery. When experiencing mania, the client tends to view the future unrealistically as highly favorable. CBT assists the client in recognizing and challenging such unrealistic or “automatic” thoughts and can help the client and the health care team recognize early trends toward mania
A nurse is caring for a client in a mental health facility and overhears the client discussing plans to harm her father-in-law physically when she is discharged. Which of the following interventions should the nurse take?
A. Ask the client to sign a contract agreeing not to harm others
B. Notify the provider of the client’s threat
C. Keep the client’s discussion confidential
D. Place the client in individual observation
A nurse is preparing to meet with a client who has borderline personality disorder. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship?
A. Introduce the concept of client confidentiality
B. Establish goals with the client
C. Define the roles of the nurse and the client
D. Facilitate change in the client’s behavior
A nurse is contributing to the plan of care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse recommend?
A. Search the client and his belongings upon arrival
B. Assign the client to a private room near the nurse’s station
C. Instruct assistive personnel to check on the client every 15 m in
D. Keep the door to the client’s room closed
Search the client and his belongings upon arrival
*The nurse should plan to search the client and all of his belongings upon arrival to the unit. This search is conducted for the client’s safety so that the nurse can identify and remove any objects that increase the client’s risk of injury or suicide. Potentially harmfully objects include razors, shoelaces, hygiene products, and tweezers
A nurse is talking with a client about his admission to a mental health unit. The client states, “I just don’t know if I should be here. What will my family think?” Which of the following responses by the nurse uses the therapeutic communication technique of reflection?
A. “It sounds like you are concerned about your family’s reaction.”
B. “What your family thinks isn’t important; you need to be concerned about getting well.”
C. “I suspect your family doesn’t seem to understand you.
D. “Many clients are concerned about the reaction of their families.”
A nurse is reinforcing teaching with the parent of a child who has a new prescription for methylphenidate to treat ADHD. Which of the following instructions should the nurse include in the teaching?
A. “Weigh your child 3 times per week.”
B. “Expect your child to experience dark-colored stools.”
C. “Administer this medication at bedtime.”
D. “You should limit your child’s intake of caffeine.”
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for venlafaxine. Which of the following statements should the nurse make?
A. “This medication is only for short-term use”
B. “This medication can be taken on an as-needed basis.”
C. “This medication will effectively reduce your physical manifestations of anxiety.”
D. “This medication should not be stopped abruptly.”
A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for valproic acid. The nurse should explain that the provider will routinely prescribe which of the following tests while the client is taking valproic acid?
A. Electrocardiogram
B. Chest X-ray
C. Thyroid function tests
D. Liver function levels
A nurse in a provider’s office is collecting data for a client who has been taking donepezil for Alzheimer’s disease. The data indicate that the client’s disease is progressing and becoming more severe. Which of the following medications should the nurse expect the provider to prescribe?
A. Megestrol
B. Galantamine
C. Memantine
D. Haloperidol
A nurse is contributing to the plan of care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority?
A. Practicing problem-solving skills
B. Understanding the medication regimen
C. Identifying indications of relapse
D. Maintaining adequate hydration
A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse recognize as an erotomaniac delusion?
A. “My coworker is trying to poison me because he is afraid I’ll take his job.”
B. “I have only met Jenny twice, but I know she’ll love me.”
C. “I am selling my house before the earthquake hits in May.”
D. “The foil on my walls prevents the government from controlling me.”
A nurse is caring for an adolescent male client who has anorexia nervosa. The client asks, “Have I done any permanent damage to my body?” Which of the following responses should the nurse make?
A. “What concerns do you have about your physical health?”
B. “Let’s wait to discuss that after you’re feeling better.”
C. “Unconsciously, you’re saying that you’re worried about your physical appearance.”
D. “I’m glad you’re concerned about the physical effects of your illness.”
A nurse is reinforcing teaching with a client who has a new prescription for lorazepam to treat alcohol withdrawal. Which of the following should the nurse identify as an adverse effect of lorazepam that the client should report to the provider?
A. Increased thirst
B. Sweating
C. Blurred vision
D. Facial flushing
A nurse is caring for a client who is dying. The client’s son appears visibly upset when he visits. Which of the following statements should the nurse make to the client’s son?
A. “Tell me how you’re feeling about your mother’s illness.”
B. “Consider bringing a support person when you visit your mother.”
C. “It is okay to feel angry when losing someone close to you.”
D. “You should think about joining a grief support group.”
A nurse in a provider’s office is reviewing the medical history of a client who asks about the use of varenicline for smoking cessation. Which of the following items in the client’s medical history indicates a precaution for the use of varenicline?
A. The client has type 1 diabetes mellitus
B. The client has a history of depression
C. The client has rheumatoid arthritis
D. The client has a history of GERD
A nurse is reinforcing teaching with a client who has a new prescription for varenicline for smoking cessation. Which of the following statements by the client indicates an understanding of the teaching?
A. “If I fail to stop smoking after 12 weeks, I will have to try another product.”
B. “I will take them medication for 7 days before I try to stop smoking.”
C. “This medication will cause me to lose weight as I stop smoking.”
D. “I will take the medication after eating a meal.”
A nurse is collecting data from a client who was recently admitted for treatment of major depressive disorder (MDD). Which of the following findings should the nurse expect the client to report? (Select all that apply)
A. Difficulty sleeping for several weeks
B. Inability to concentrate on simple tasks
C. Desire for sexual activity with multiple partners
D. Not bathing for several days
E. Lack of enjoyment from a long-time hobby of gardening
1. Difficulty sleeping for several weeks
2. Inability to concentrate on simple tasks
3. Not bathing for several days
4. Lack of enjoyment from a long-time hobby of gardening
*The nurse should expect a client who has MDD to report either difficulty sleeping or excessive, indecisiveness and an inability to concentrate, a lack of personal hygiene and self-care, and anhedonia, which is the inability to feel pleasure or happiness from a hobby or activity that once provided these positive feelings
A nurse on an acute care mental health unit is collecting data from a client who was admitted following an opioid overdose. The client states that he wants his admission to remain confidential. Which of the following responses should the nurse make?
A. “There is no way we can keep the details of your admission a secret from other people.”
B. “Being admitted as a confidential client will cost extra.”
C. “Only the staff involved in your care will know the details of your admission.”
D. “We will only release information about your admission to your family members.”
“Only the staff involved in your care will know the details of your admission.”
*Keeping the details of a client’s admission and care confidential is a legal requirement as as part of the nurse’s ethical duty. The nurse should inform the client that only members of the staff who are involved in his care will have access to information about his admission and treatment
Fluoxetine
*The nurse should expect the provider to prescribe fluoxetine for a client who has bulimia nervosa. It is an SSRI used most frequently for the treatment of depression. It is thought to assist in the treatment of binge eating associated with bulimia by decreasing the craving for carbohydrates. It is prescribed for bulimia at 3 times the dosage that is used for the treatment of depression
A nurse is reinforcing teaching with the guardian of a female adolescent client who has bulimia nervosa. Which of the following statements by the guardian indicates an understanding of the teaching?
A. “My daughter is at risk for developing high blood pressure.”
B. “It is important for my daughter to have regular dental checkups.”
C. “I should weigh my daughter daily for several weeks.”
D. “Bleeding during my daughter’s periods will increase.”
A nurse is caring for a client who has schizophrenia and is experiencing auditory and visual hallucinations. Which of the following actions should the nurse take?
A. Ask the client what the voices are saying
B. Encourage the client to use reality testing
C. Limit the client’s exposure to noise
D. Place the client in seclusion
Encourage the client to use reality testing
*A client who is experiencing hallucinations can become frightened or agitated. The nurse should encourage the client to perform reality testing during periods of hallucinations by looking at the faces of other clients in the area. If the other clients do not appear frightened, the client should identify that the perception is a hallucination and not real.
A nurse at a long term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions?
A. “We will be serving breakfast in 10 min. I will stay here while you get ready.”
B. “It’s Monday morning. I know that your favorite television shows are on this evening.”
C. “I see that you have a new photo on the wall. Can you tell me who that girl is?”
D. “It’s almost time for your appointment. Let me do your hair for you and brush your teeth.”
“It’s almost time for your appointment. Let me do your hair for you and brush your teeth.”
*When a client with dementia has periods of confusion, the AP should allow the client additional time to complete activities that can be performed independently. Insisting on completing the task for the client or attempting to hurry her can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or needs it
A nurse is reinforcing teaching with a client who has anxiety and a new prescription for diazepam. Which of the following statements should the nurse make?
A. “Feelings of sedation should resolve in about 1 week.”
B. “There is no risk of physical dependence with this medication.”
C. “You can decrease the dose when you feel especially anxious.”
D. “It will take several months for you to feel the maximum benefit maximum benefit of the medication.”
A nurse is teaching with a client in the day room of an acute care mental health facility. The client accuses the nurse of being “too bossy” and states the nurse does not have the right to pressure anyone. Which of the following responses should the nurse provide?
A. “What makes you say that?”
B. “Tell me what I said that made you feel uncomfortable.”
C. “Why are you feeling pressured by me?”
D. “You shouldn’t make negative statements since I’m trying to help you.”
“Tell me what I said that made you feel uncomfortable.”
*This statement uses the therapeutic technique of exploring to ask the client to explain her feelings. This can help the client view the situation objectively, enabling the nurse to determine the client’s thoughts and promoting trust between the client and nurse
A nurse is caring for 4 clients in a community mental health facility. For which of the following clients should the nurse provide a tertiary care intervention?
A. A client who has generalized anxiety disorder and reports increased anxiety and insomnia
B. A client who is expressing hopelessness during a crisis
C. A client who is recovering from a crisis and asks for help in completing the recovery process
D. A client who is having difficulty coping with stress and wants to learn relaxation techniques
A client who is recovering from a crisis and asks for help in completing the recovery process
*This client should receive tertiary care interventions such as a referral to community groups or facilities to complete recovery from a crisis. Tertiary care is designed to provide support for mental and physical healing after a crisis occurs
A nurse is assisting with the admission of a client who has alcohol use disorder. Which of the following statements indicates that the client is using denial as a coping mechanism?
A. “I put in extra hours at work so I won’t think about drinking.”
B. “I know that wine is good for my heart, so that’s why I drink some each evening.”
C. “I make up for my drinking by taking my partner on nice vacations.”
D. “I am able to go to work every day, so I don’t have a problem.”
A nurse is assisting with a support group for clients who are nearing discharge from an acute care mental health facility. During a group session, a client states, “I’m scared about being discharged.” Which of the following responses should the nurse offer?
A. “Maybe you are not ready to be discharged yet.”
B. “Are there others in the group who have similar feelings they would like to share?”
C. “You ought to be happy that you’re being discharged.”
D. “How many in the group feel this member is not yet ready to be discharged?”
“Are there others in the group who have similar feelings they would like to share?”
*Some of the goals of a support group include providing improved interpersonal relationships, mutual support, and methods to decrease stress. By asking if others in the group have similar feelings, the nurse allows the client to hear that feelings regarding discharge are not unique; also, the client might receive support from group members who express similar feelings
A nurse in an acute mental health facility is caring for a client who states, “This place is ridiculous. I can’t stand spending another day here!” Which of the following responses should the nurse make?
A. “You should focus on the good things so the bad things seem less important.”
B. “I’m sure tomorrow will be a better day.”
C. “You shouldn’t be so negative when you are young and physically healthy.”
D. “Let’s talk for a while about the events of your day.”
A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client’s behavior?
A. Confront the client for breaking the rules
B. Stand close to the client to offer comfort and support
C. Speak to the client with clear, calm, caring statements
D. Escort the client to the nurse’s station
A nurse is assisting with the care of a client who has a terminal illness. The client yells at the nurse, “Get out of my sight. You’ve always bothering me about something!” Which of the following responses should the nurse offer?
A. “You don’t have to yell. I’m sorry you feel like I’ve bothered you.”
B. “I’ll go, but I’ll be back in a little while when you have calmed down.”
C. “I’m going to have to ask you to be quieter since there are other clients on this unit.”
D. “I’ll be here if you would like to talk about how you feel.”
A home health nurse is talking with the partner of a client who has dementia. Which of the following statements by the partner indicates that the client is displaying signs of apraxia?
A. “Yesterday, my partner put on a jacket upside down.”
B. “My partner has trouble reading the newspaper.”
C. “My partner often repeats words.”
D. “Last week, my partner did not recognize the sound of the alarm clock.”
A nurse in an acute mental health facility is assisting with the plan of care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse recommend?
A. Encourage the client to focus on personal hygiene
B. Limit the hours the client sleeps each day
C. Instruct the client to practice thought-stopping
D. Make negative statements about the client’s behavior
A nurse is preparing to care for a client who was brought to a community health facility by her caregiver, who states that the client refuses to eat. The nurse notes the client has lost weight, avoids making eye contact, and defers questions to the caregiver. Which of the following actions should the nurse take?
A. Make sure the caregiver is present when interviewing the client
B. Document how the caregiver responds when told that the client looks neglected
C. Ask the client why she refuses to eat the caregiver’s food
D. Identify sources of stress for the caregiver
Identify sources of stress for the caregiver
A nurse on an acute mental health unit is caring for a client who is experiencing a manic episode with agitation. Which of the following actions should the nurse take?
A. Schedule the client for group therapy
B. Discourage the client from napping during the day
C. Encourage the client to participate in physical activity
D. Allow the client to spend time alone
A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for lithium. Which of the following directions should the nurse provide?
A. Decrease sodium intake while taking lithium
B. It may take 5 days before the medication is effective
C. Take the medication on an empty stomach
D. Increase the fluid intake to 2000 mL (67.6 oz) daily
A nurse is reinforcing teaching with a client who has a prescription for a tricyclic antidepressant. Which of the following instructions should the nurse share?
A. “Take this medication within 1 hour of waking each morning.”
B. “Limit your alcohol intake to 2 drinks per week while taking this medication.”
C. “It can take 6 weeks to achieve the full therapeutic effect of this medication.”
D. “Stop taking the medication if you experience dizziness.”
A nurse is interacting with a client who has a psychotic disorder when the client suddenly turns her head as if listening to something and says, “The boss says she is going to hit me with a stick!” Which of the following responses should the nurse offer?
A. “The boss can’t hurt you with that stick
B. “Why are you talking to yourself?”
C. “I don’t see anyone, but it sounds like you are frightened.”
D. “There isn’t anyone here but you and me, so you need to explain.”
A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the nurse that he isn’t going to attend any further sessions and states, “I don’t have time for all that talking.” Which of the following responses should the nurse provide?
A. “It must be difficult for you to talk about family problems.”
B. “You should continue attending the family counseling sessions until the therapist tells you to stop.”
C. “If you continue to go to family counseling, I’m sure you’ll be able to resolve your family problems soon.”
D. “I think you need to continue family therapy if your partner and children want to receive further counseling.”
“It must be difficult for you to talk about family problems.”
*The nurse’s response indicates empathy for the client’s feelings and is an example of the therapeutic communication technique of verbalizing what the client implied. With this technique, the nurse helps him focus on the actual reason for not wanting to continue family therapy
A nurse is heling evaluate the plan of care for a client who has antisocial personality disorder. Which of the following client actions indicates that he is making progress with the treatment? (select all that apply)
A. Assisting another client who has depression to fill out a menu
B. Nominating himself to chair the client government meeting
C. Requesting a weekend pass to go home
D. Serving as the judge for a unit talent show
E. Informing the nurse that the staff provides excellent care to clients
1. Assisting another client who has depression to fill out a menu
2. Requesting a weekend pass to go home
*Clients who have antisocial personality disorder tend to lack empathy for others and often display an inability to connect with others. Assisting another client indicates the client’s willingness to help and connect with others and demonstrates rules and have a lack of respect for authority. Requesting a weekend pass indicates the client’s willingness to follow unit rules and demonstrates progress with treatment
A nurse is reinforcing teaching with the family of a client who has Alzheimer’s disease about donepezil. Which of the following statements should the nurse include?
A. “Donepezil can improve cognitive functioning during the earlier stages of the disease.”
B. “Donepezil cures the disease process if it is started upon first recognition of dementia.”
C. “Donepezil provides long-term reversal of memory loss in the last phase of the disease.”
D. “Donepezil accelerates the breakdown of acetylcholine within the client’s brain.”
“Donepezil can improve cognitive functioning during the earlier stages of the disease.”
*The nurse should inform the client’s family that donepezil is used to treat the manifestations of mild to severe Alzheimer’s disease. Although donepezil does not prevent the progression of Alzheimer’s disease, it is intended to prolong the client’s ability to function in the early stages of the disease
A nurse is teaching a client who has schizophrenia about involuntary commitment. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
A. “My family cannot commit me because I am homeless.”
B. “Even when I’m calm, I’ll be forced to take psychotropic medication.”
C. “At least 2 doctors must support the commitment application.”
D. “At least 2 doctors must support the commitment application.”
“At least 2 doctors must support the commitment application.”
*Involuntary commitment is a court-ordered mandate requiring admission of a client to receive mental health services either at an outpatient mental health facility. At least 2 doctors or other mental health professionals must agree that the client should be involuntarily committed to ensure due process and avoid accidentally committing the client
A nurse is teaching a client who has seasonal affective disorder (SAD) about the use of light therapy. Which of the following statements should the nurse make?
A. “Light therapy suppresses the natural nighttime release of melatonin.”
B. “You should plan your light therapy session before going to bed.”
C. “You should begin with 2-minute light therapy sessions and gradually progress to 10-minute sessions.”
D. “Light therapy is less effective at treating SAD than antidepressant medications.”
“Light therapy suppresses the natural nighttime release of melatonin.”
*Melatonin is produced nocturnally by the pineal gland; larger amounts are produced during months containing more hours of darkness. These large amounts of melatonin seem to cause SAD in clients who are susceptible to this disorder. Light therapy is thought to improve depression by suppressing melatonin production and increasing serotonin production
A nurse in a provider’s office is reviewing the results of a mental status exam for a client who has early manifestations of dementia. Which of the following pieces of information from the examination describes the client’s cognitive status?
A. The client has a flight of ideas
B. The client shows a deficit in recent memory
C. The client has a flat affect
D. The client is well groomed
A nurse is determining the total score for a client’s Alcohol Use Disorders Identification Test (AUDIT) by assigning a score of 0 to 4 for each of the client’s answers. For which of the following self-reported findings should the nurse assign the client a score of 4?
A. The client’s frequency of alcohol intake is typically 3 times per week
B. The client misses work once a month because of his alcohol intake
C. Alcohol intake does not cause the client to have feelings of guilt
D. Last month, the provider suggested that the client reduce his alcohol intake
Last month, the provider suggested that the client reduce his alcohol intake
*When determining a client’s total score for the AUDIT self-reported version, the nurse should assign a score of 4 if the client indicates that a friend, relative, or health care provider recommended decreasing his alcohol consumption at least once during the last 12 months
A nurse is caring for a client who has social anxiety disorder. Which of the following client statements should the nurse expect?
A. “I am embarrassed to eat in public.”
B. “I often feel like I am going to have a heart attack.”
C. “I struggle to control my constant worry.”
D. “I have to step over the cracks in the sidewalk or else something bad might happen.”
“I am embarrassed to eat in public.”
*The nurse should recognize that this statement describes social disorder. Clients who have this disorder experience severe anxiety or fear of behaving in a manner that can be negatively viewed by others. These clients attempt to avoid activities such as eating or speaking in public. If they are unable to avoid activities that trigger the anxiety, clients experience severe anxiety and emotional distress
A nurse is speaking with a client whose partner was killed unexpectedly. The client states, “I just don’t know what to do now.” Which of the following actions should the nurse take?
A. Talk to the client about available community resources
B. Distract the client by discussing events not related to the crisis
C. Reassure the client that he will feel better soon
D. Give the client advice about what to do during the next few days
Talk to the client about available community resources
*Initial steps should be taken to make a client who is experiencing a crisis feel safe and less anxious. The priority for the nurse is to ensure the client is safe, which includes assessing any thoughts of self-harm. After promoting client safety, the nurse should let the client know what personal and community resources are available. The nurse should determine the client’s perception of the crisis, availability of support, and ability to cope with the crisis.
A nurse is assisting with the care of a client who has a substance use disorder and was involuntarily admitted by court order for 90 days. When the nurse attempts to administer prescribed oral lorazepam to decrease the client’s manifestations of withdrawal, the client aggressively refuses. Which of the following actions should the nurse take?
A. Place the lorazepam on hold
B. Request a prescription for IM lorazepam
C. Request that another nurse attempt to administer the lorazepam
D. Place the lorazepam in the client’s food
Place the lorazepam on hold
*Clients who are in a health care facility due to an involuntarily admission retain the right to refuse treatment, including prescribed medications. Therefore, the nurse should hold the medication, document the client’s wishes in the medical record, and notify the provider of the refusal
A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements should the nurse make?
A. “Limit daytime napping to an hour maximum.”
B. “Watch TV as you fall asleep.”
C. “If you aren’t able to sleep, you can get out of bed and read a book.”
D. “Track the number of hours that you sleep each night.”
A nurse is collecting data from a toddler who has a fractured arm. Which of the following findings should the nurse identify as a possible indication of physical abuse?
A. The parent provides a history that is inconsistent with the child’s injury
B. The child is brought to the health care facility immediately following the injury
C. The parent requests to remain present with the child throughout treatment of the injury
D. The child clings to the parent when the nurse begins to examine the injury
Hallucinations
*Positive symptoms fall into the following categories: content of thought, form of thought, perception, or sense of self. The nurse should identify that hallucinations fall under the category of perception and cause the client to experience sensory perceptions that are not associated with reality. Other positive symptoms include delusions, depersonalization, and concrete thinking
A nurse is caring for a client who has schizophrenia and has been admitted to the mental health unit. The client has a history of aggression and has been continually pacing the hallway in an agitated manner over the past hour. Which of the following responses should the nurse make?
A. “It’s a beautiful day outside. Let’s take a walk together.”
B. “Sit down so we can try a relaxation exercise.”
C. “Would you like your antianxiety medication now?”
D. “You are pacing back and forth. Can you tell me what you are feeling?”
“You are pacing back and forth. Can you tell me what you are feeling?”
*The first action the nurse should take using the nursing process is to collect data from the client. By asking the client to identify feelings of anxiety, the nurse promotes trust and can assist the client with decreasing anxiety before an episode of aggression occurs
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms?
A. “I just feel so hopeless.”
B. “The government has been watching my house.”
C. “I am unable to remember to brush my teeth.”
D. “I no longer enjoy the activities I used to love.”
A nurse in a community mental health facility is caring for a group of clients. Which of the following clients should the nurse identify as experiencing an adventitious crisis?
A. A client who has a new diagnosis of severe bipolar disorder
B. A client who is depressed following a devastating fire in her home
C. A client who is experiencing acute grief following his father’s death
D. A client who is experiencing postpartum depression following the birth of her first child
A client who is depressed following a devastating fire in her home
*The nurse should identify that a client who is experiencing depression following a house fire is experiencing an adventitious crisis. An adventitious crisis is unplanned and not a part of everyday life. The crisis can result from a natural disaster, a national disaster, or a crime of violence
A nurse is collecting data from a client who has moderate cognitive decline due to stage 4 Alzheimer’s disease. Which of the following findings should the nurse expect?
A. The client requires assistance with eating
B. The client frequently gets lost due to wandering
C. The client has bladder incontinence
D. The client is able to identify the names of family members
A nurse is reinforcing teaching with a client who has a new prescription for buspirone. Which of the following statements by the client indicates an understanding of the teaching
A. “I need to watch for signs of dehydration.”
B. “I need to have my kidney function monitored while taking this medication.”
C. “I should take this medication on an empty stomach.”
D. “I might not notice the effects of this medication for several weeks.”
“I might not notice the effects of this medication for several weeks.”
*The effects of buspirone develop slowly. The initial response takes at least a week, and a peak response takes several weeks. Because of the delayed action, buspirone should not be taken as a PRN medication for the relief of anxiety
A nurse is reinforcing teaching with a client who has anxiety and a new prescription for buspirone. Which of the following pieces of information should the nurse include in the teaching?
A. “Buspirone carries a high potential for abuse.”
B. “Avoid consuming grapefruit juice when taking this medication.”
C. “Take the medication 4 times daily.”
D. “The peak effects of buspirone occur within 1 week.”
A nurse on an eating disorders acute care unit is collecting data from a client and observes the presence of lanugo on her skin. The nurse should identify that this finding is consistent with which of the following eating disorders?
A. Anorexia nervosa
B. Bulimia nervosa
C. Binge eating disorder
D. Pica
A nurse is caring for a client who is postoperative following an amputation of the left lower leg. The client states, “I can’t believe this happened to me. I don’t deserve this.” Which of the following responses should the nurse make?
A. “Tell me what you’re feeling about what has happened?”
B. “The feelings you’re having are normal following an amputation.”
C. “I agree with you. You did not deserve this.”
D. “What makes you say that you don’t deserve this?”
A nurse is caring for a child who has a diagnosis of terminal brain cancer. The mother states, “I feel numb and can’t believe this is happening to us.” Which of the following interventions is the nurse’s priority?
A. Explore effective ways of family coping
B. Encourage the family’s expression of their feelings
C. Discuss the disease and its manifestations with family members
D. Instruct the family about anticipatory grieving
Encourage the family’s expression of their feelings
*The first action the nurse should take using the nursing process is to assess the family by encouraging them to express their feelings about their child’s illness. This assessment will allow the nurse to understand the particular needs of the family better as they prepare to face their child’s death
A nurse is caring for a client who left the facility without permission and has had outside privileges revoked for 1 week. The client asks the nurse if she can take a short walk outside the facility. Which of the following responses should the nurse provide?
A. “Your privileges have been revoked. I’d be glad to help you find something to do inside the unit.”
B. “I think it would be good for you to take a walk, but your doctor has take away your privileges.”
C. “You decided to leave the hospital without permission. Why are you asking to go outside today?”
D. “We shouldn’t discuss this. Let’s talk about what you want to do when you are discharged.”
“Your privileges have been revoked. I’d be glad to help you find something to do inside the unit.”
*This response demonstrates the technique of offering self to the client. It reinforces the reality of the client’s current situation, offers the client another option for a permitted activity, and conveys the nurse’s willingness to spend quality time with the client
A nurse in a mental health clinic is caring for a client who is grieving over the sudden death of his child. Which of the following statements should the nurse offer?
A. “Be grateful for the time you had with your child.”
B. “I know you are glad your child didn’t suffer.”
C. “You are young and can have more children.”
D. “I cannot imagine how you are feeling right now.”
“I cannot imagine how you are feeling right now.”
*The nurse should allow the client to express his feelings and talk about emotions without telling the client how to feel or diminishing the client’s grief. This therapeutic response by the nurse by the nurse allows the client to express grief while providing the opportunity for further communication
A nurse on a mental health unit is caring for a client who begins throwing objects at other clients. Which of the following actions is the priority nursing intervention?
A. Attempt to restrain the client’s arms
B. Administer an anti-anxiety medication
C. Place the client in seclusion
D. Tell the client to stop the behavior
A nurse is collecting data from a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make?
A. “Please try to focus on our conversation.”
B. “There is nothing over there except a chair.”
C. “Tell me what you are seeing by that chair.”
D. “Whatever you are seeing by chair is not real.”
“Tell me what you are seeing by that chair.”
*The nurse should recognize that the client might be experiencing a hallucination and should collect further data about the situation. This response directly asks the client about the hallucination and promotes further communication about the possible perceptual alteration
A nurse is reinforcing teaching with the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching?
A. “We will not set time limits for discussing her delusions.”
B. “We will avoid reacting to her command hallucinations.”
C. “She might lose weight due to her medications.”
D. “She might be having a relapse if she stops attending social events.”
A nurse is reinforcing teaching with a client who reports depression and has a new prescription for an SSRI medication. Which of the following statements should the nurse make?
A. “You should avoid foods with tyramine while taking this medication.”
B. “If the adverse effects are too bothersome, stop taking the medication.”
C. “Drinking alcohol is allowed with this type of medication.”
D. “The effect of the medication may take several weeks to be felt.”
“The effect of the medication may take several weeks to be felt.”
*The nurse should reinforce with the client that the therapeutic effect of SSRIs may take 1 to 4 weeks to be felt. If no effect is felt by 4 weeks, the client should notify the provider, and a change in dosage or medication may be prescribed. The client should continue to take the medication as directed, even if symptoms improve. A relapse of depression can occur if the medication is stopped
A nurse is contributing to the plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse recommend including in the plan?
A. Schedule specific times for the client to eat
B. Compromise about foods the client is willing to eat
C. Focus on the client’s weight gain goal
D. Weigh the child at the same time every week
A nurse is collecting data on a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect?
A. Demonstrates extroverted behavior to gain attention
B. Is always on guard around other people
C. Is rigid about following rules and procedures
D. Has an exaggerated sense of self-importance
Swallowing antidepressant pills
*The nurse should assess the lethality of a client’s suicide plan and identify whether it is a hard or soft method. Ingesting antidepressants or other pills is considered a soft method because it has a lower risk of resulting in death than hard methods. Hard methods include jumping from a high place, carbon monoxide inhalation, hanging, and using a gun
A nurse is caring for a client who returns to the unit from day pass 2 h ours late. The client has slurred speech, and the nurse smells alcohol on the client’s breath. What should the nurse say to the client in response to this situation?
A. “Why are you returning late from your day pass?”
B. “How much did you drink? You know drinking is against the rules.”
C. “We will need to discuss your actions after you’ve had a chance to sleep.”
D. “I’m disappointed that you were not more responsible while on a day pass.”
A nurse is contributing to the plan of care for a client who has a physical dependence on alprazolam and must discontinue the medication. Which of the following actions should the nurse recommend?
A. Taper the medication gradually over several weeks
B. Encourage participation in stimulating physical activity
C. Monitor the client for a return of anxiety for up to 72 hr following discontinuation of the medication
D. Implement restraints and seclusion as needed
A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for which of the following substances?
A. Amphetamines
B. Opiates
C. Barbiturates
D. Hallucinogenics
A nurse is reinforcing teaching with a family member of a client who has newly diagnosed with nyctophobia. Which of the following statements by the family member shows an understanding of the teaching?
A. “He becomes anxious during electrical storms.”
B. “He avoids parties because he is afraid of meeting strangers.”
C. “He quit his job because he was afraid of entering the storage room.”
D. “He is unable to sleep without a light on.”
A nurse on a mental health unit is caring for a client who has social anxiety disorder and is exhibiting signs of panic. Which of the following actions should the nurse take to reduce the client’s level of anxiety?
A. Accompany the client to an area with increased environmental stimuli
B. Suggest that the client lies down and rests
C. Place the client in seclusion
D. Encourage the client to practice deep breathing
Encourage the client to practice deep breathing
*The nurse should encourage the client to practice slow deep-breathing exercises to elicit relaxation. The nurse should demonstrate the technique and practice it along with the client. Focus on taking slow, deep breaths can help divert the client’s attention from feelings of anxiety
A nurse in a health clinic is treating a child who has bruises. The nurse suspects child abuse, but the provider disagrees and sends the client home. Which of the following actions should the nurse take?
A. Request a social services consultation
B. Contact the child’s guardian to discuss the suspicion
C. Report the provider’s actions to the state medical board
D. Report the suspected abuse to law enforcement
A nurse on a rehabilitation unit is reinforcing teaching with the partner of a client who is experiencing stimulant withdrawal. Which of the following statements by the partner indicates an understanding of the teaching?
A. “Increased energy is a sign of withdrawal.”
B. “Depression is a manifestation of withdrawal.”
C. “Decreased appetite is a manifestation of withdrawal.”
D. “Delirium tremens can occur during withdrawal.”
A nurse is talking with a client who has major depressive disorder. Which of the following client statements should the nurse identify as a covert statement of suicidal ideation?
A. “I don’t want to live any longer.”
B. “I think every day about killing myself.”
C. “My parents will be happier when I’m dead.”
D. “I won’t have to deal with things much longer.”
“I won’t have to deal with things much longer.”
*The nurse should listen closely for overt and covert statements that can indicate a client’s intent to commit suicide. Covert statements can indicate in an indirect way a client’s plan for suicide or wish to no longer be alive. Covert statements are more difficult to identify because they do not openly express the client’s suicidal thoughts like overt statements. The nurse should collect further data from the client’s suicidal ideation and implement interventions to reduce the risk of a suicide attempt
A nurse is caring for a client who has depression. The client states, “I am too tired and depressed to attend group therapy today.” Which of the following responses should the nurse make?
A. “Attending group therapy, even if you’re tired, is an important part of your treatment.”
B. “That’s okay if you’re too tired to attend group therapy today, but you will have to go tomorrow.”
C. “It is normal to feel tired when you’re feeling depressed. The others in group therapy also feel this way.”
D. “I agree with your decision to wait for participation in group therapy until you begin to feel better.”
“Attending group therapy, even if you’re tired, is an important part of your treatment.”
*Through this therapeutic response, the nurse is giving the client information to make an informed decision. Group therapy benefits clients who have depression by promoting peer support and reducing social isolation
A nurse is reinforcing teaching with the partner of a client who has alcohol use disorder. Which of the following statements by the partner indicates an understanding of the teaching?
A. “Having 6 beers in 2 hours is considered too much.”
B. “My partner is not at risk for cancer due to alcohol consumption.”
C. “My partner should consume no more than 20 drinks of alcohol in a week.”
D. “There is no genetic risk with abuse alcohol.”
A nurse is collecting data from a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make?
A. “I thought I hear something too.”
B. “Is someone telling you something?”
C. “What are you hearing?”
D. “There is nobody in that chair for you to listen to.”
“What are you hearing?”
*This open-ended question allows the nurse to find out what the client is hearing without validating the hallucination as real. The nurse should watch the client for anxiety or fear and ensure that the hallucination is not commanding the client to hurt self or others. After an assessment of the client’s hallucinations is complete, the nurse can develop a plan to decrease the hallucinations.
A nurse at an acute care facility is assisting with the care of a client who is receiving IV antibiotic treatments for an infection. The client reported daily alcohol use at home. On the seconds day of admission, the client becomes agitated, hypertensive, and tachycardic. Which of the following actions should the nurse plan to take?
A. Administer methadone when agitation increases
B. Administer zolpidem before meals
C. Request a prescription for a different antibiotic
D. Request a prescription for chlordiazepoxide
Request a prescription for chlordiazepoxide
*The nurse should recognize these findings as indications of withdrawal from alcohol and should intervene to decrease adverse manifestations. Chlordiazepoxide, an anxiolytic, is a benzodiazepine prescribed for alcohol withdrawal that reduces manifestation and can help prevent seizures and delirium tremens
A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first?
A. Assertive community treatment
B. Supportive group
C. Private counseling
D. Vocational rehabilitation services
Assertive community treatment
*Evidence-based practice indicates the nurse should first refer the client to an assertive community treatment (ACT). An ACT program should be most beneficial for this client who has bipolar disorder with rapid cycling, as professional help will be available to the client 24 hours a day for crisis management. A multidisciplinary team approach assists clients in managing their mental illness so inpatient hospitalization can be avoided
A nurse is reinforcing teaching with the parents of a school-aged child who has attention deficit hyperactivity disorder (ADHD). Which of the following instructions should the nurse include?
A. “Ignore your child’s attention-seeking behaviors that are not dangerous.”
B. “Administer ADHD medications within 30 min of your child’s bedtime.”
C. “Continue with an activity as planned even if your child becomes frustrated.”
D. “Expect your child to gain weight after starting ADHD medications.”
“Ignore your child’s attention-seeking behaviors that are not dangerous.”
*The nurse should instruct the parents about the use of planned ignoring. This technique ignores attention-seeking behaviors that are not dangerous to the child or others. If the child learns that the behavior will not elicit the desired response, then the behavior should decrease
A nurse is reviewing the laboratory report of a client who is taking risperidone. The nurse should identify that which of the following result indicates a potential adverse reaction to the medication?
A. Elevated blood glucose
B. Elevated WBC count
C. Decreased platelet count
D. Decreased aspartate transaminase (AST)
Elevated blood glucose
*The nurse should identify that all second-generation antipsychotic medications such as risperidone can cause diabetes, weight gain, and dyslipidemia. To monitor for diabetes, a baseline glucose reading should be obtained and compared to a glucose reading taken 12 weeks later. If there is no change after 12 weeks, glucose should be monitored annually
A nurse is caring for an adult client who has alcohol use disorder. The client states she is refusing further treatment and is leaving the mental health facility. Which of the following actions should the nurse take?
A. Request a prescription for restraints from the provider
B. Notify security and ask them to lock the unit’s exit doors
C. Notify the client’s family of her intent to leave
D. Ask the client to sign an against medical advice form
Ask the client to sign an against medical advice form
*The client has the right to refuse treatment and leave the mental health facility unless involuntarily committed. The nurse should ask the client to sign an against medical advice (AMA) form stating that she is choosing to leave the facility against the recommendation of her provider
A nurse is contributing to the plan of care for a client who has borderline personality disorder and self-mutilates. Which of the following treatment approaches should the nurse recommend?
A. Restrict participation in group therapy sessions
B. Establish consequences for self-mutilation
C. Maintain close observation of the client
D. Provide an unstructured environment
A nurse on an inpatient mental health unit is caring for a client who is angry and showing signs of potential violence. Which of the following actions should the nurse take to de-escalate the client’s anger?
A. Call security personnel for a show of force
B. Inform the client that restraints will be used as a consequence for verbal abuse
C. Speak to the client in a loud, forceful voice
D. Give the client extra personal space
A nurse is planning care for a client who has dissociative disorder and is experiencing flashbacks while in public. Which of the following interventions should the nurse include in the plan to help the client recognize and counter the flashbacks?
A. Encourage reality testing
B. Provide opportunities for socialization
C. Consistently remind the client of past traumatic events
D. Discourage client expressions of negative feelings
A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for this client?
A. Walking with a staff member
B. Playing ping-pong in the dayroom with another client
C. Playing basketball with other clients in the gym
D. Riding on a stationary bike alone in the fitness room
A nurse is caring for a client who was just admitted for treatment of anorexia nervosa. Which of the following actions should the nurse take?
A. Discuss the nutritional value of foods during meal times
B. Weight the client 3 mornings per week
C. Allow the client to exercise for up to 1 hour per day
D. Monitor the client for 1 hour following meals and snacks
A nurse on an inpatient mental health unit is planning care for a client who was admitted following a suicide attempt. Which of the following actions should the nurse include in the plan?
A. Keep the door of the client’s room to open while the client is awake
B. Ensure that the client’s meal tray contains no knives
C. Observe the client swallow medications
D. Have a staff member observe the client once every 30 minutes
A nurse is caring for a client who has post-traumatic stress disorder (PTSD) and who is undergoing eye movement desensitization and reprocessing (EMDR) therapy. The nurse should identify that EMDR includes which of the following strategies?
A. Exposes the client to circumstances that trigger the PTSD
B. Assists the client with behavioral modification
C. Encourages the client to visualize a relaxing scene when traumatic memories occur
D. Uses stimuli to change how the client processes the trauma
Uses stimuli to change how the client processes the trauma
*EMDR uses stimuli such as tapping, eye movements, or audio sounds combined with verbalization of the traumatic event by the client. While the client recalls the traumatic event, these stimuli create neurological and physiological changes in how the client integrates the memories. EMDR is a type of psychotherapy carried out during several sessions by a therapist who is trained in the method
A nurse in a rehabilitation center for clients with substance use disorders is collecting data from a client who is being admitted. The client tells the nurse, “I am afraid of other people finding out that I am in a rehabilitation center.” Which of the following responses should the nurse make?
A. “You don’t need to worry about that.”
B. “You should be proud of yourself for getting treatment.”
C. “Why do you care what other people think?”
D. “Tell me more about how you are feeling about being here.”
A nurse is assisting with preparing an in-service session about Alzheimer’s disease for a group of newly licensed nurses. Which of the following findings should the nurse include as an early manifestation in the progression of the disease?
A. Forgetting material that was just read
B. Losing the ability to feel emotions
C. Experiencing changes in physical abilities such as swallowing
D. Having difficulty controlling the bladder
A public health nurse is planning methods of providing health assistance for community members. Which of the following community interventions is an example of primary prevention?
A. Serving as a staff member in a rape crisis center
B. Provide referrals to 12 step programs for community members being discharged from rehabilitation centers
C. Demonstrating stress-release exercises to members of the community
D. Leading a support group for newly divorced community members
A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client should the nurse recognize as demonstrating the defense mechanism of displacement?
A. “I smoked for years, but now I cannot stand to be around cigarette smoke.”
B. “I didn’t get the promotion at work because my boss hates me.”
C. “My partner yelled at me, so I made the cat go outdoors.”
D. “I won’t worry about losing my job until my child’s break from school is over.”
A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take?
A. Encourage the client to attend assertive behavior sessions
B. Ensure staff members set limits on the client’s behavior
C. Tell the client to socialize more with other clients on the unit
D. Frequently implement measures to increase the client’s self-esteem
Ensure staff members set limits on the client’s behavior
*The nurse should ensure all staff members set limits on the client’s behavior. The limits should be clear and realistic and realistic and address specific behaviors. Also, the nurse should provide clear boundaries and consequences for the client
A nurse is caring for a client who has end-stage lung cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of Kubler-Ross’ stages of grief?
A. “I would give anything to live to see my grandchildren born.”
B. “Can you make sure there hasn’t been a mistake with my test results.”
C. “I feel so sad that I will be leaving my partner all alone.”
D. “What have I done to deserve this death sentence?”
“I would give anything to live to see my grandchildren born.”
*Kubler-Ross identified common responses of clients who experience any form of loss. These responses are divided into 5 stages. While each of these stages is experienced by clients, they are not necessarily experienced in a linear fashion or in the exact same order. Some clients can experience a stage more than once. This response shows that the client is in the bargaining stage and might be trying to make a deal with a higher power to prolong life
A nurse is collecting data from a client who has major depressive disorder. Which of the following questions is the priority for the nurse to ask the client?
A. “Do you have any close friends?”
B. “Can you describe how you feel about what’s happening?”
C. “Have you thought about hurting yourself?”
D. “How are you dealing with being away from your family?”
A nurse in an ambulatory clinic is caring for a client who has an injured arm and periorbital ecchymosis. The nurse suspects intimate partner violence. Which of the following nursing interventions should the nurse take first?
A. Notify the nursing supervisor
B. Prepare the client for an X-ray
C. Contact social services
D. Check the client’s injuries
A nurse is reinforcing teaching about decreasing codependent behaviors with the family of a client who has alcohol use disorder. Which of the following statements by a family member indicates an understanding of the teaching?
A. “We will help her financially if she loses her job.”
B. “We will not hold her responsible for her alcohol use.”
C. “We will routinely search for and remove any alcohol in her home.”
D. “We will not let our moods be changed by her behavior.”
“We will not let our moods be changed by her behavior.”
*The nurse should explain to the family that alcohol use is self-inflicted and that the client must take responsibility for her actions. The family should not allow the client’s dysfunctional behavior to control their environment. Establishing boundaries with the client is the family’s first step in reducing the codependent behaviors
A nurse in a rehabilitation center is planning to reinforce medication teaching with a client who is being discharged following treatment for opioid use disorder. Which of the following medications should then nurse expect the provider to prescribe for the client?
A. Diazepam
B. Disulfiram
C. Bupropion
D. Methadone
Methadone
*Methadone is used to decrease symptoms during the withdrawal phase of opioids. It is also used following withdrawal for maintenance therapy, as methadone decreases the euphoric effects of opiate drugs. Methadone can also lead to dependence, and the client will eventually need to be withdrawn from the medication
Reduced aggression
*Clients who have ADHD can experience a low tolerance for frustration, which can result in aggressive behaviors. Although psychosocial interventions should include developing coping mechanisms and cognitive behavior therapy, the client might require medication to manage aggressive behaviors. The nurse should monitor for reduced aggression when a client who has ADHD is taking a mood stabilizer such as lithium. Additional outcomes of mood-stabilizing medications include decreased impulsivity
A nurse is leading a group therapy session for a group of clients. Which of the following client statements should indicate to the nurse that the client is using the defense mechanism of rationalization?
A. “I became a team manager because I’m not tall enough to succeed at basketball.”
B. “I don’t want to talk right now about the fire that destroyed my home.”
C. “I take amphetamines because it’s the only way I can keep up with all the studying for my classes.”
D. “I will spend a day cleaning my house when I feel like my life is out of control.”
“I take amphetamines because it’s the only way I can keep up with all the studying for my classes.”
*Rationalization is the act of justifying unacceptable thoughts or behaviors with a seemingly acceptable explanation. Rationalization allows the client to protect the ego and avoid taking responsibility for actions or thoughts that can cause shame of embarrassment
A nurse in a mental health facility is planning to promote the development of a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take?
A. Begin each interaction by sharing a personal story
B. Identify professional boundaries during the initial interaction
C. Agree with the client’s perceptions and emotions to encourage free expression
D. Allow the client to meet with the nurse at any time during the day
A nurse is interviewing a client who is seeking help for intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence?
A. “Last night my partner beat me worse than ever before.”
B. “It’ll be easier just to make my partner mad and get the violence over with.”
C. “I believe my partner is remorseful and won’t hurt me again.”
D. “I only got shoved a little bit, and it was my fault for coming home late.”
A nurse is caring for a client who presents with a fractured wrist. The nurse suspects intimate partner violence. Which of the following interventions is the nurse’s priority?
A. Help the client develop a safety plan
B. Teach the client empowerment skills
C. Provide information about a support group for intimate partner abuse
D. Make a follow-up appointment with the primary provider
A nurse is caring for a client who has a neurocognitive disorder and wanders at night. Which of the following actions should the nurse take to promote the client’s safety?
A. Put the client’s mattress on the floor
B. Keep the lights off in the client’s room at night
C. Limit snacks during the evening hours
D. Turn off the client’s radio or music player at night
A nurse is reinforcing teaching with a family member of a client who has dementia. Which of the following statements should the nurse include?
A. “Dementia is often associated with a reaction to a new medication.”
B. “Dementia is usually reversible with prompt treatment.”
C. “Dementia develops rapidly over a matter of hours or days.”
D. “Dementia is commonly associated with Alzheimer’s disease.”
A home health nurse is collecting data from a client who has advanced dementia and whose caretake recently passed away. The client is not violent or suicidal. For which of the following treatment settings should the nurse recommend a referral for this client?
A. Partial hospitalization
B. Adult daycare facility
C. Inpatient geropsychiatric unit
D. Long-term nursing care center
A nurse is reinforcing teaching with the caregiver of a child who has pica. Which of the following statements should the nurse identify as an indication that the caregiver understands the teaching?
A. “My child will have this disorder for the rest of his life.
B. “My child will return undigested food to his mouth because of this disorder.”
C. “My child might try to eat dirt when we are at the playground.”
D. “My child will need to be repositioned during feedings.”
A nurse is reestablishing a therapeutic relationship with a client. Which of the following actions should the nurse perform during the orientation phase of the the relationship?
A. Research the client’s condition
B. Explain confidentiality to the client
C. Provide the client with information about her disorder
D. Summarize the client’s goals
Explain confidentiality to the client
*The nurse should explain confidentiality to the client during the orientation phase of the therapeutic relationship. Other tasks the nurse should accomplish during this phase include establishing a rapport and specifying a contract containing the date, time, and place of future meetings with the client
A nurse is caring for a client who requests information about smoking cessation using nicotine gum. For which of the following reasons should the nurse recommend another over-the-counter smoking cessation product to the client?
A. The client is overweight
B. The client follows a vegan diet
C. The client has dentures
D. The client has insomnia
A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving?
A. The death was a result of violence
B. The client expresses anger over the loss
C. This is the client’s first experience of the loss of a family member
D. The client demonstrates reorganization of behavior
A nurse is caring for a client who reports that the television set in the room is really a 2-way radio states, “Voices are coming from the TV, and everything we say in this room is being recorded.” Which of the following responses should the nurse make?
A. “What we say is not being recorded.”
B. “Let’s ignore the voices and talk about something else.”
C. “That must be very frightening.”
D. “Why do you think the TV is a 2-way radio”
A school nurse is providing care to a student who is angry and states, “My parents don’t know I’m gay, so I can’t visit my girlfriend in the hospital while she receives cancer treatment.” Which of the following forms of grief is the client experiencing?
A. Chronic grief
B. Uncomplicated grief
C. Disenfranchised grief
D. Delayed grief
A nurse is collecting data from a client who has adjustment disorder. Which of the following statements by the client should the nurse recognize as a manifestation of this disorder?
A. “I am unable to remember my address.”
B. “I feel like I am living in a fog.”
C. “I sometimes cannot remember large blocks of time.”
D. “I could have done something to prevent my cousin’s death.”
“I could have done something to prevent my cousin’s death.”
*The nurse should recognize that this statement indicates adjustment disorder, which occurs as a response to a stressful event. Manifestations can include guilt, depression, anxiety, and anger. These feelings might accompany physical manifestation, social withdrawal, or work or academic changes. The disorder can be treated with antidepressant medications
A nurse is assisting with the care of a client who has schizophrenia and is being discharge from an acute mental health setting. Which of the following should be included in the discharge plan?
A. Refer the client to respite care services
B. Provide a list of primary preventative mental health group
C. Enroll the client in a 12-step program
D. Contact an intensive outpatient program
Contact an intensive outpatient program
*A client who has received in-patient treatment for schizophrenia can benefit from an intensive outpatient program. These programs allow clients to receive step-down care similar to what was provided in the inpatient setting to stabilize their condition further
A nurse in an emergency department is caring for a client who states, “I tripped over the dog again.” The nurse notes the client has multiple lacerations and ecchymoses and sees in the client’s medical record that she visited 2 months ago for similar injuries. Which of the following actions should the nurse take?
A. Ask the client what she believes she did to deserve being physically abused
B. Avoid documenting subjective verbatim statements from the client regarding injuries
C. Talk to the client about making a safety plan
D. Explain the cycle of violence to the client
Talk to the client about making a safety plan
If the nurse concludes that physical abuse is occurring, it is important to support the client and take actions such as counseling the client about making a safety plan. The nurse should understand local laws regarding intimate partner violence and should report the incident as required
A nurse in a provider’s office is reinforcing teaching with a client who is experiencing stress due to the loss of a job. Which of the following instructions should the nurse give?
A. Drink no more than 6 cups of coffee per day
B. Exercise for 140 minutes each week
C. Get 6 hours of sleep every night
D. Sleep 30 minutes later each morning
A nurse in a long-term care facility is caring for a client who has dementia and becomes increasingly agitated in the afternoon hours. Which of the following actions should the nurse take first?
A. Place the client in a private room
B. Apply soft wrist restraints to the client
C. Administer haloperidol to the client
D. Offer diversionary activities for the client
A nurse in a provider’s office is reviewing the medical record of a client who has major depressive disorder and a new prescription for phenelzine. Which of the following items in the client’s history should the nurse report to the provider?
A. The client uses a transcutaneous electrical nerve stimulation (TENS) unit for back pain
B. The client has frequent headaches
C. The client takes glucosamine sulfate for arthritis
D. The client has a history of tinnitus
A nurse is collecting data from a group of clients who have paraphilic disorders. Which of the following client statements should then nurse identify as an indication that a client has necrophilia?
A. “I was arrested for making obscene phone calls.”
B. “I enjoy taking nitrous oxide prior to have an orgasm.”
C. “I like my partner to urinate on me during sex.”
D. “I often fantasize about having intercourse with a corpse.”
“I often fantasize about having intercourse with a corpse.”
*A client who has a paraphilic disorder obtains sexual arousal or orgasm from stimuli or acts that are outside of societal norms. Fantasizing about having sex with a corpse is an expected behavior for a client who has an “other specified” paraphilic disorder of necrophilia. The presence of a paraphilic disorder does not necessarily mean the client will act on the thought or ideas
Swiss cheese
*Swiss cheese, and many other cheeses, are high in tyramine, which can interact with phenelzine. Phenelzine is an MAO that blocks neurotransmitters such as tyramine from being broken down. Therefore, ingestion of foods containing tyramine can increase the client’s blood pressure and can cause a stroke. Foods that are high in tyramine should be avoided by a client who is taking an MAOI
A nurse is collecting data from a client who is receiving disulfiram for alcohol aversion therapy. The client is experiencing palpitations and reports nausea, a headache, and extreme thirst. The nurse should identify that which of the following situations is occurring?
A. The client is experiencing mild acetaldehyde syndrome
B. The client is having delirium tremens
C. The client is experiencing disulfiram toxicity
D. The client is not having a therapeutic response to disulfiram
The client is experiencing mild acetaldehyde syndrome
*The nurse should recognize that these manifestations are an indication of acetaldehyde syndrome, which occurs when alcohol consumption is combined with disulfiram use. The client’s current manifestations represent the mild form of acetaldehyde symptoms that can occur by consuming as little as 7 mL (0.2 oz) of alcohol
A nurse is teaching a client who has bipolar disorder and a new prescription for lithium. The nurse should identify that which of the following statements by the client indicates an understand of the teaching?
A. “I should take my lithium on an empty stomach.”
B. “I can take ibuprofen for headaches while taking lithium.”
C. “I need to limit my salt intake while taking lithium.”
D. “I am likely to gain weight while taking lithium.”
A nurse in an acute mental health facility is participating in a group therapy session in which client enact situations to help them process past events. The nurse should identify that which of the following types of group therapy is being carried out?
A. Psychoeducational group
B. Psychodrama group
C. Family therapy group
D. Self-help group
A nurse is caring for a client who has schizophrenia and states, “My doctor is trying to kill me.” Which of the following responses should the nurse make?
A. “Why would you say that your doctor is trying to kill you?”
B. “It must be frightening to feel that your doctor is trying to kill you.”
C. “You doctors wants to help you, not kill you.”
D. “How long has your doctor been trying to kill you.”
A nurse in an acute care mental health facility is assisting with the evaluation of the plan of care for a client who has major depressive disorder and was admitted 1 week ago following a suicide attempt. Which of the following client statements should indicate to the nurse that the treatment plan has been effective?
A. “I just don’t want to talk about anything that has happened before my admission.”
B. “I was feeling completely hopeless when I tried to kill myself.”
C. “I am feeling really great today, and I think I am ready to go home.”
D. “I want to punch the doctors who put me in this hospital.”
“I was feeling completely hopeless when I tried to kill myself.”
*This statement should indicate to the nurse that the client is meeting a short-term goal of being willing to discuss painful feelings that occurred at the time of the suicide attempt. The nurse should also evaluate whether the client is now willing to see help when feelings o self-harm occur
A nurse is collecting data from an older adult client about possible abuse by her caregiver. Which of the following techniques should the nurse use?
A. Avoid directly asking the client if she has been abused
B. Use a confrontational speech
C. Maintain a nonjudgmental tone
D. Avoid being in the room alone with the client
A nurse is caring for a client who has Alzheimer’s disease. The client’s adult son reports that the client has begun wandering away from home. Which of the following responses should the nurse make?
A. “You should plan to move your mother into your home soon.”
B. “Place a complex lock at the top of each door that leads outside.”
C. “It is time to place your mother in a long-term care facility.”
D. “Have you reminded your mother about the dangers of wandering away from home?”
“Place a complex lock at the top of each door that leads outside.”
*The nurse should instruct the client’s son to place complex locks at the top of doors that lead outside to prevent the client from wandering away from home. The nurse should also encourage the client’s son to place a non-removable medical alert bracelet on the client with the client’s name, address, and telephone number
A nurse is contributing to the plan of care for a client who has binge-eating disorder. Which of the following interventions should the nurse recommend?
A. Weigh the client each day
B. Provide the client with small, frequent meals
C. Observe the client during meals for hiding food
D. Offer liquid supplements during meals
Disulfiram
*The nurse should anticipate a prescription for disulfiram for a client who is in the maintenance phase of alcohol withdrawal. Disulfiram promotes refraining from alcohol through aversion therapy. Any intake of alcohol while the client is taking the medication will result in intense nausea and vomiting, headaches, respiratory difficulties, and confusion
A nurse is reinforcing teaching with a client who has major depressive disorder and is scheduled to begin electroconvulsive therapy (ECT). Which of the following pieces of information should the nurse include?
A. “If you’re trying a benzodiazepine medication, you should take it before the procedure.”
B. “You can expect to wake up about 15 minutes after the procedure.”
C. “After the first procedure, you should expect to have ECT sessions monthly for a year.”
D. “ECT is the primary treatment for most clients who have depression.”
A nurse is caring for a client who is receiving cognitive-behavioral therapy. The client tells the nurse, “Nothing good ever happened during my marriage.” When using cognitive reframing, which of the following responses should the nurse provide?
A. “Let’s discuss what you considered to be negative about your marriage.”
B. “What activities do you enjoy that take your mind off your marriage experience?”
C. “What did you learn from your marriage to help you in the future?”
D. “Only you can understand how your marriage negatively affected your life.”
“What did you learn from your marriage to help you in the future?”
*Cognitive-behavioral therapy, specifically cognitive reframing, asks the client to restructure thoughts to try to learn from situations perceived as negative. The intended purpose is to help the client identify misconceptions and work toward developing more accurate and positive perceptions. This response encourages the client to look at the situation more positively to find the benefits of experience
A nurse on a mental health unit is receiving reports about a group of clients. Which of the following client statements is an example of a persecutory delusion?
A. “I am the mayor of this town.”
B. “My doctor is in love with me.”
C. “That other nurse is trying to poison me.”
D. “The end of the world is coming tonight.”
Hallucinations
*The nurse should identify that hallucinations can be an adverse effect of fluoxetine and can also indicate that the client is experiencing serotonin syndrome. Serotonin syndrome can be caused by too high a dose of fluoxetine or an interaction with another medication. Other adverse effects of serotonin syndrome can include diarrhea, sweating, fevers, tachycardia, abdominal pain, and increased blood pressure. The nurse should notify the provider immediately
A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions is the nurse’s priority?
A. Offer the client finger foods every 2 hr
B. Determine if the client is a danger to herself
C. Monitor the client’s vital signs every 2 hr
D. Move the client to a quiet area
A nurse is caring for a client with borderline personality disorder who has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?
A. Co-dependents support group
B. National Alliance on Mental Illness
C. Dialectical behavior treatment group
D. Dual diagnosis treatment group
A nurse is reinforcing with the guardian of a school-aged child who has ADHD and a new prescription for clonidine. Which of the following statements by the guardian indicates an understanding of the teaching?
A. “I will not allow my child to eat anything within 2 hours of taking the medication.”
B. “I can expect my child to be drowsy while taking this medication.”
C. “I will give my child a dose of the medication at noon every day.”
D. “I will cut the tablet in half before giving it to my child.”
A nurse is collecting data from a client who reports being abused by his partner. Which of the following actions should the nurse take?
A. Tell the client that he is morally obligated to press charges against his partner
B. Inform the client that photographs of his injuries must be taken
C. Tell the client that he will be taken to a safe house
D. Give the client a detailed explanation of all of the procedures that must be performed
Give the client a detailed explanation of all of the procedures that must be performed
*A client who reports abuse will often experience fear and anxiety. Providing sensitive and supportive care by explaining all procedures and providing privacy for the client can decrease the client’s anxiety and feelings of vulnerability
A nurse on a pediatric mental health unit is receiving reports on 4 children. Which of the following reports should the nurse expect for a child who has an autism spectrum disorder?
A. The child cannot sit still to be read to
B. The child displays neck jerking tics
C. The child has a ritualized behavior pattern
D. The child bullies the other children on the unit
A nurse is observing a client who has schizophrenia. The client is in the dayroom when another client asks him if 2 items of clothing match. He replies, “A match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on.” The nurse should identify these statements as which of the following speech alterations?
A. Clang association
B. Echolalia
C. Word salad
D. Associative looseness
A nurse is caring for a client who has an alcohol use disorder and is currently undergoing alcohol detoxification. Which of the following interventions should the nurse provide at this time?
A. Administer substitution therapy medications
B. Teach the client the physical symptoms of withdrawal
C. Provide the client with information about a 12 step program
D. Identify the causes of the client’s alcohol use disorder
A nurse is caring for a client who has schizophrenia. The client states, “I like to play ball. Walk down the hall. Be careful; don’t fall.” The nurse should identify that the client is using which of the following patterns?
A. Pressure speech
B. Circumstantial speech
C. Clang association
D. Flight of ideas
A nurse is caring for a client who is receiving care at an inpatient alcohol treatment facility. Which of the following actions should the nurse identify as an example of an intentional tort?
A. Administering an incorrect dose of benzodiazepine
B. Informing the client’s family member of the admission without the client’s knowledge
C. Informing the client that an injection will be administered if the client remains agitated
D. Failing to recognize suicide risks, which results in the client’s death
A nurse is caring for a client who has bipolar disorder and a new prescription for valproic acid. Which of the following actions should the nurse take?
A. Monitor the client’s liver function
B. Avoid giving the medication with food or milk
C. Counsel the client regarding medication dependency
D. Limit intake of foods containing tyramine
A nurse is talking with the partner of a client who has alcohol use disorder. Which of the following statements by the client’s partner should the nurse identify as an indication of codependence?
A. “My partner is addicted to both alcohol and cocaine.”
B. “I have an alcohol problem just like my partner does.”
C. “My partner only drinks to deal with her major depression.”
D. “I call my partner’s boss when she’s had too much to drink to go to work.”
“I call my partner’s boss when she’s had too much to drink to go to work.”
*The nurse should identify this statement as an indication of codependency in which the codependent individual takes on extra responsibilities and assists the client who has the alcohol use disorder in meeting obligations. This caregiving affects the individual’s perception of self-worth and can cause the individual to put the needs of the client first
A nurse is caring for a client who was admitted to the mental health unit for substance use disorder. The client states, “I am a nurse on the medical-surgical floor, and I don’t want my coworkers to know I have been diverting drugs.” Which of the following actions should the nurse take?
A. Advise the client that her supervisor will be transferring her to another unit following treatment
B. Inform the client that the information will be shared with the treatment team
C. Explain to the client that there is a legal obligation to inform coworkers of her actions
D. Tell the client her coworkers’ opinion should not matter
A nurse is planning care for a client who is experiencing complicated grief following the unexpected death of his partner. Which of the following actions should the nurse plan to take first?
A. Positively reinforce new coping skills that increase the client’s self-esteem
B. Encourage the client to seek support from a counselor who specializes in grief
C. Determine which stage of grief the client is experiencing
D. Allow the client to express angry feelings associated with the grief
A nurse in a provider’s office is documenting the results of a general survey of a client who is new to the practice. The client reports an inability to find pleasure in any activities she previously enjoyed. Which of the following terms should the nurse use to describe the client’s mood?
A. Anergia
B. Flat effect
C. Apathy
D. Anhedonia
A nurse in a provider’s office is collecting data from a client who has been taking varenicline. Which of the following reports from the client indicate a therapeutic response to the medication?
A. The client is taking fewer opioid pain relievers
B. The client no longer has delirium tremens
C. The client has reduced cravings for cigarettes
D. The client is less hyperactive
A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility’s gym. Which of the following responses should the nurse make?
A. “Can you tell my why you do not want to participate in the planned group activity?”
B. “Do you understand that psychotropic medications cause weight gain?”
C. “The aerobics class will be more effective at burning calories than walking.”
D. “It sounds like you have come up with an alternative exercise that works for you.”
A nurse is reinforcing teaching about ethics with a newly licensed nurse. Which of the following actions should the nurse include as an example of beneficence?
A. Taking a continuing-education course about recognizing risk factors of suicide
B. Spending extra time reorienting a client who is experiencing command hallucinations
C. Acknowledging and accepting a client’s refusal of a psychotropic medication
D. Describing the purpose, action, and side effects of a psychotropic medication
Spending extra time reorienting a client who is experiencing command hallucinations
*The nurse should include this action as an example of beneficence, which is the duty to act to promote the good of others. Reorienting a client who is experiencing command hallucinations is the best interest of the client and can protect the client from harm
A nurse is caring for a client who has Alzheimer’s disease and a new prescription for donepezil. Which of the following actions should the nurse take?
A. Monitor the client’s liver function while taking this medication
B. Increase the dosage of the medication every 72 hours
C. Offer the client a PRN aspirin while taking the medication
D. Administer the medication at bedtime
A nurse on an acute mental health unit is collecting data from a client who has obsessive-compulsive disorder (OCD). Which of the following behaviors should the nurse expect?
A. Being intentionally dishonest
B. Jumping rapidly between topics of conversation
C. Tapping the 4 sides of a light switch
D. Mimicking the movements of another person
A nurse is collecting data from a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?
A. “I wish I had been nicer and more generous to my wife before she died.”
B. “I told my wife to go to the doctor, but she wouldn’t listen to me.”
C. “I think about my wife all the time when I go on outings with my family.”
D. “I feel so empty without my wife that it’s hard to get up every morning.”
A nurse in a mental health clinic is caring for a client who has anxiety disorder related to post-traumatic stress disorder (PTSD). Which of the following actions by the client indicates a therapeutic response to treatment?
A. The client spends most of the day in bed
B. The client prefers to talk about things other than his anxiety
C. The client seeks out environments with increased stimuli
D. The client identifies situations that cause anxiousness
The client identifies situations that cause anxiousness
*The client’s ability to identify situations that lead to episodes of anxiety is an indication of a therapeutic response to treatment. If the client can foresee and prepare for these situations, the client will have a better chance of controlling emotions
A nurse is collecting data from a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicates that the client is physically dependent on the amphetamines?
A. The client exhibits paranoia
B. The client reports having insomnia
C. The client reports eating excessively
D. The client has an increased heart rate
The client reports eating excessively
*When amphetamine is taken at a therapeutic dose, it causes appetite suppression. Abrupt withdrawal of amphetamine can result in abstinence syndrome in a client who is physically dependent on the medication. Indications of physical dependence include excessive eating, exhaustion, depression, prolonged sleep, and a craving for more amphetamine
A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take?
A. Withhold PRN anti-anxiety medication
B. Provide the client with a stimulating activity prior to bedtime
C. Keep the client’s room well-lit at night
D. Encourage the client to make decisions about her daily routine
A nurse is providing teaching to a client who has social anxiety disorder and a new prescription for paroxetine. Which of the following statements should the nurse include in the teaching?
A. “You can take this medication when needed.”
B. “The medication takes a few weeks to build up in your system.”
C. “You should plan to take this medication for 6 months.”
D. “Relapsing after withdrawing from this medication is rare.”
A nurse is assisting with the admission of a client who has antisocial personality disorder to an acute care unit. The client is admitted under court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to display?
A. Relief about finally receiving care for a problem for which was previously afraid to ask for
B. Anger with the nursing staff for hospitalizing him against his will
C. Withdrawal from others due to shame over his recent actions
D. Remorse for stealing and destroying the car
Dental erosion
*The nurse should expect dental erosion in a client who has bulimia nervosa. The binging and purging behavior with induced vomiting leads to dental caries and enamel erosion from the hydrochloric acid content of emesis. Induced vomiting can also cause parotid swelling. Continued vomiting can place the client at risk of esophageal or gastric rupture
A nurse in an acute care mental health facility observes a client who has bipolar disorder to begin to shout and use offensive language toward a visitor. Which of the following actions should the nurse take?
A. Give the client 2 options for ending the situation
B. Move quickly to stand directly in front of the client before speaking
C. Direct other clients to move toward the client as a show of force
D. Tell the client that the conversation will be ended if the shouting continues
A nurse is collecting data from a newly admitted client. To establish trust, which of the following actions should the nurse perform during the orientation phase of the nurse-client relationship?
A. Inform the client that the admission is confidential
B. Introduce the client to other clients in the dayroom
C. Assist the client with facilitating behavioral change
D. Determine coping strategies that the client has used in the past
A nurse in a mental health clinic is collecting data from an older adult client who is tearful and reports sleep disturbances. The client tells the nurse, “All of my friends have died, and my children are too busy for me.” Which of the following actions should the nurse take first?
A. Contact the client’s family for support
B. Administer the Geriatric Depression Scale
C. Refer the client to his provider for an antidepressant medication
D. Encourage the client to join a senior support group
Administer the Geriatric Depression Scale
*The first action the nurse should take using the nursing process is to assess the client by administering the Geriatric Depression Scale to determine if he is clinically depressed and, if so, assess the severity of the depression. This assessment will allow the nurse to understand the particular needs of the client
A nurse is caring for a client who is experiencing delusions. Which of the following actions should the nurse take?
A. Focus on the client’s delusions
B. Debate the content of the delusions with the client
C. Validate that the delusions are real
D. Ask the client to describe his feelings about the delusions
Increased blood pressure
*Lorazepam is a benzodiazepine that is administered to a client who is experiencing alcohol withdrawal for stabilizing vital signs, preventing seizures, and treating delirium tremens. The nurse should anticipate the provider to prescribe lorazepam for increasing blood pressure
A nurse is caring for a client who has a depressive disorder. The client states, “I’m no good, spend your time with someone else.” Which of the following responses should the nurse provide?
A. “Why do you put yourself down?”
B. “Did you go to group therapy yesterday?”
C. “You will feel better soon if you follow your treatment plan.”
D. “I’m going to stay with you for a while if you would like to talk.”
Pure vanilla extract
*The nurse should instruct the client to avoid alcohol-containing substances such as pure vanilla extract while taking disulfiram. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension
A nurse is assisting with the admission of a client who has a hip fracture to the medical surgical care unit. The client states, “I’ve never been in the hospital before, and I’m feeling a lot of anxiety.” Which of the following responses should the nurse make?
A. “You’re feeling anxious about being in the hospital for the first time.”
B. “Anxiety while in the hospital is a feeling many people experience.”
C. “Why do you think you feel anxious about being in the hospital?”
D. “What activities do you enjoy when you are not in the hospital?”
Seizures
*Although uncommon, seizures are a potential adverse effect of TMS
A nurse is caring for a client who has generalized anxiety disorder (GAD). Which of the following goals should the nurse include in the discharge plan of care for this client?
A. Use whistling or singing as a distraction to control hallucinations
B. Make independent decisions about daily events
C. Verbalize a realistic perception of personal appearance
D. Decrease the use of ritualistic behavior
Make independent decisions about daily events
*A client who has GAD demonstrates indecisiveness and has unrealistic and persistent anxiety most days of the week. This can cause the client to avoid situations that produce anxiety or to procrastinate necessary decision-making. The ability to make independent decisions about daily events is a goal the nurse should include in the discharge plan of care for the client
A nurse working in a retirement community is collecting data from an older adult client. Which of the following manifestations should the nurse identify as an expected age-related change?
A. Making occasional errors when balancing a checkbook
B. Confusion with time or place
C. Poor judgment
D. Changes in mood
Making occasional errors when balancing a checkbook
*The nurse should identify that making occasional errors when balancing a checkbook is an expected age-related change in an older adult. Other manifestations can include needing occasional assistance with operating appliances, forgetting a name or an appointment and then remembering it later, difficulty finding the correct use of a word, and becoming tired after social activities
A nurse in a mental health clinic is collecting data from a client who recently lost her partner after an extended illness. Which of the following statements by the client indicates that she might be experiencing major depressive disorder as opposed to typical grief?
A. “I still sometimes get angry over this happening to my partner.”
B. “I feel no pleasure without my partner in my life.”
C. “I see reminders of my partner every day.”
D. “I feel like I should have done more to take care of my partner.”
A nurse is caring for a client with schizophrenia who has been taking chlorpromazine for the pas 2 months. Which of the following findings demonstrates that the chlorpromazine has been effective?
A. The client reports that hallucinations occur less frequently
B. The client sleeps uninterrupted for 6 hours each night
C. The client reports that she is the “most important person on the unit.”
D. The client demonstrates stereotyped behaviors
The client reports that hallucinations occur less frequently
*The nurse should identify that a primary action of chlorpromazine, when used to treat schizophrenia, is to reduce hallucinations. Chlorpromazine, a first-generation conventional antipsychotic medication, is effective in decreasing delusions, hallucinations, and agitation. It can also treat manic behavior in clients who have bipolar disorder
A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client?
A. Tell the client that the nurse will talk to him at his request
B. Allow the client to skip group activities if he chooses
C. Leave the client alone for frequent rest periods throughout the day
D. Build trust with the client by sitting quietly with him
Build trust with the client by sitting quietly with him
*The nurse should build trust with the client to convey interest in the client’s concerns. Offering self by sitting with the client and using silence are actions that promote trust, which encourages the client to speak more openly about issues and concerns
A nurse is interacting with a client in a substance use disorder program. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission?
A. “I was just using the medication to help me out during a rough time in my life. I can stop whenever I want.”
B. “This all happened because my spouse is unemployed. That puts an enormous amount of stress on me.”
C. “I have read that problems with substances can have a variety of predisposing factors.”
D. “I just don’t want to talk about it. Anyway, there is nothing you can do to help.”
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for lorazepam. Which of the following statements should the nurse include?
A. “Taking an antacid with the medication will decrease stomach upset.”
B. “Expect the medication to cause insomnia for the first 1 to 2 weeks.”
C. “Drinking caffeinated beverages will decrease the effectiveness of the medication.”
D. “Increase the dosage if the effectiveness of the medication decreases.”
“Drinking caffeinated beverages will decrease the effectiveness of the medication.”
*The nurse should inform the client that consuming caffeine while taking benzodiazepines such as lorazepam will result in decreased effectiveness of the medication. Caffeine is a stimulant, and lorazepam is a CNS depressant; therefore, the substances will counteract each other. The client should avoid consumption of caffeine while taking this medication
A nurse is caring for a client who spent the past several minutes mumbling about being “doomed to die.” The client is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurse’s priority?
A. Obtain a prescription for PRN medication for agitation
B. Attempt to reduce environmental stimuli
C. Request a prescription for physical restraints
D. Place the client in seclusion
A nurse is assessing a client who has a new diagnosis of major depressive disorder. Which of the following questions is the priority for the nurse to ask?
A. “How would you describe your mood?”
B. “How are you sleeping?”
C. “Do you drink alcohol or use other substances?”
D. “Do you ever think about suicide?”
“Do you ever think about suicide?”
*The diagnosis of major depressive disorder indicates that the greatest risk for this client is suicide. Therefore, the priority for the nurse to ask is about suicidal ideation. Research shows that clients who have depressive disorders are at high risk for suicide due to the common presence of recurring thoughts of death
A nurse is collecting data from a client who lost his mother a few months ago and is feeling depressed. Which of the following findings should cause the nurse to suspect the client has major depressive disorder?
A. The client focuses on reuniting with his mother
B. The client is unable to express pleasure
C. The client reports feeling anger
D. The client reports experiencing intense sadness
A nurse is assisting with the plan of care for a client who has vegetative signs of depression. Which of the following actions should the nurse include in the plan?
A. Limit snacking between meals
B. Schedule regular naptimes during the day
C. Weigh the client monthly
D. Provide decaffeinated beverages
A nurse is caring for a client who has major depressive disorder. The client states, “I might as well be dead. I have always been a failure.” Which of the following responses should the nurse make?
A. “Why do you think you feel this way?”
B. “You have a great deal to offer in life.”
C. “Let’s discuss these feelings further.”
D. “Feelings like a failure is expected with depression.”
A nurse is talking with an adolescent client who has major depressive disorder. The client tells the nurse into a situation in which he feels a friend betrayed him. Which of the following responses should the nurse offer?
A. “Why should you feel betrayed by this friend?”
B. “You’ll get over this friend in time.”
C. “How does this situation make you feel?”
D. “Jealousy will not help your friendship.”
A nurse is collecting data from a client who has bipolar disorder and is in maniac state. Which of the followings is the highest priority?
A. The client reports sleeping 2 to 3 hours per night
B. The client speaks to the nurse in a demanding tone
C. The client reports not attending group therapy
D. The client reports not taking medication for the past 2 weeks
A nurse is collecting data from a client who has post-traumatic stress disorder (PTSD) due to a sexual assault that occurred 3 months ago. Which of the following findings should the nurse expect?
A. Increased hours of sleep each day
B. Repeatedly talking about the assault
C. Dreaming about the assault
D. Decreased responsiveness to stimuli
A nurse is collecting data from a client who was in a motor-vehicle crash that killed her sibling. The client is shaking and asks, “What can I do now?” Which of the following questions is the nurse’s priority?
A. “Are you thinking about hurting yourself?”
B. “Do you have someone who could come here to be with you?”
C. “How will this situation affect your life?”
D. “What qualities have helped you cope with a crisis in the past?”
A nurse is reinforcing teaching with a client who has an anxiety disorder about nonpharmacological ways to promote good sleep habits. Which of the following recommendations should the nurse make?
A. “Schedule 20 minutes of aerobic exercise during the hour before bedtime.”
B. “Eliminate all caffeinated beverages from your diet.”
C. “Sleep for extra time when you can.”
D. “Eat a light snack containing carbohydrates before bedtime.”
A nurse is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?
A. Address the client in a high pitched voice
B. Speak to the client firmly and authoritatively
C. Remove potentially harmful objects before leaving the client alone in the room
D. Offer the client low-calorie or no-calorie fluids
A nurse is assisting with the admission of a client who reports hearing voices telling him what to do. Which of the following actions should the nurse take?
A. Instruct the client to sit in a quiet place when he hears voices
B. Ask the client to repeat what the voices are saying
C. Tell the client that the voices do not exist
D. Provide therapeutic touch when the client seems anxious
A nurse is collecting data from a client who has bipolar disease. Which of the following actions is an indication the client is experiencing a manic stage?
A. The client speaks rapidly with a sense of urgency
B. The client touches everything within her reach
C. The client states that she is unable to enjoy her favorite activities
D. The client moves slowly and maintains a fixed gaze
A mental health nurse is reviewing a process recording of a therapy session with a client. Which of the following statements should the nurse identify as an example of the communication technique of reflection?
A. “I notice you are pulling on your hair when we discuss your dismissal.”
B. “That statement made by the other client appears to have upset you.”
C. “Since writing in your journal is frustrating, we should look at this activity more closely.”
D. “Give me an example of a time when you felt no one understood you.”
A nurse is assisting with the plan of care for a client who is scheduled for electroconvulsive therapy (ECT). Which of the following interventions should the nurse add to the plan of care for this client?
A. Maintain a clear liquid diet for 6 to hours prior to ECT
B. Allow the client to sleep for 3 to 4 hours following ECT
C. Administer IM epinephrine to the client prior to ECT
D. Reorient the client to the environment after ECT
Multiple motor and vocal tics
*The nurse should expect a child who has Tourette’s disorder to display multiple motor and vocal tics. A tic is a sudden physical movement or vocalizations of sounds or words that are unrelated to the topic of conversation. Tics can change in frequency, severity, and location. Tourette’s disorder is an inherited condition that causes clients to have multiple physical and 1 or more vocal tics
A nurse on a mental health unit is caring for a client who asks the nurse out to dinner. Which of the following responses should the nurse provide?
A. “You should ask one of the other client if they’d like to go to dinner with you.”
B. “Why are you asking me out to dinner?”
C. “We have a professional relationship, not a personal relationship.”
D. “We should discuss this some other time.”
A nurse is reinforcing teaching with a client who has a prescription for clozapine. Which of the following statements should the nurse include in the teaching?
A. “You should have your white blood cell count checked once per week for 6 months.”
B. “You should check your weight every 3 days for weight loss.”
C. “You might experience frequent loose stools.”
D. “You might experience ringing in your ears.”
A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion?
A. “A tornado is going to wipe us all out in 9 days.”
B. “My brain is dead, and my body is slowly rotting away.”
C. “The government is after me because I know top-secret information.”
D. “The TV is purposely playing commercials for things I don’t like.”
A nurse is assisting with a community presentation about Alzheimer’s disease. The nurse should conclude that a member of the group requires further reinforcement of teaching when she identifies which of the following findings as a manifestation of Alzheimer’s disease?
A. Impaired judgment
B. Sudden confusion
C. Decreased attention span
D. Short-term memory loss
A nurse is collecting data from a client who has schizophrenia. The client suddenly states, “I’m blue, so are you, and I’m leaving on a choo, choo, choo!” The nurse should identify the client’s statement as which of the following speech patterns?
A. Clang association
B. Word salad
C. Neologism
D. Echolalia
A nurse is collecting data from a client prior to the administration of lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose?
A. Report of nausea with frequent episodes of emesis
B. Weight gain of 1.8 kg (4 lb) since the start of treatment
C. Fine tremors present in both hands
D. Serum lithium level of 1.1 mEq/L
Report of nausea with frequent episodes of emesis
*The nurse should identify that gastrointestinal upset with nausea and frequent emesis is an early indication of lithium toxicity; therefore, the nurse should withhold the prescribed dose and obtain a serum lithium level. The nurse should check the client for indications of dehydration, which further increases the risk of lithium toxicity
A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client?
A. Continue to talk if the client does not provide an immediate verbal response
B. Use platitudes when talking with the client
C. Ask the client direct questions
D. Speak to the client using simple and concrete terminology
ataxia
*The nurse should identify that ataxia, which is the lack of coordination of body movements, is a manifestation of advanced lithium toxicity. Other manifestations can include seizures, blurred vision, severe hypotension, large output of dilute urine, and clonic movements as signs of advanced lithium toxicity. The nurse should notify the provider immediately if these symptoms occur
A nurse is reinforcing teaching with a client who wants to stop smoking by using nicotine lozenges. Which of the following statements should the nurse make?
A. “Drink water directly before taking the lozenge.”
B. “Place the lozenge under your tongue and let it dissolve.”
C. “Limit your use to no more than 20 lozenges per day.”
D. “Take 2 4-mg lozenges right after waking up in the morning.”
Lorazepam
*Alcohol withdrawal psychosis can begin within g8 to 10 hours following alcohol cessation and is a medical emergency because it can lead to unconsciousness, seizures, or delirium. The nurse should prepare to administer the benzodiazepine lorazepam, which can be given by mouth or intramuscularly
A nurse is caring for a client who has Alzheimer’s disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take?
A. Talk to the client from 2-arm lengths away
B. Obtain assistance to restrain the client for safety
C. Firmly state to the client that morning care will be performed
D. Call the provider to request a prescription for an antipsychotic medication
A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association?
A. “Her mannerologies are poor.”
B. “My dog blank a boa to supreme heights.”
C. “I can play the flute while wearing a suit. You are cute.”
D. “My joints ache. My friend is in the joint.”
“I can play the flute while wearing a suit. You are cute.”
*The nurse should recognize that this statement is an example of clang association. Clang association refers to the use of words that are based on sound rather than meaning. A client who has schizophrenia will often use words that rhyme or have a similar beginning sound
A nurse is contributing to the plan of care for a client who has anorexia nervosa. The nurse should identify that which of the following actions is contraindicated for this client?
A. Explaining that tube feeding are necessary if the client refuses oral intake
B. Weighing the client each day prior to any oral intake
C. Permitting the client to spend some quiet time alone after each meal
D. Refraining from commenting on what the client is eating during mealtime
Permitting the client to spend some quiet time alone after each meal
*The nurse should directly observe the client for at least an hour following meals. This intervention prevents the client from purging or discarding hidden food. Therefore, permitting the client to have alone time following meals is contraindicated for this client’s plan of care
A nurse is establishing a relationship with a client who has major depressive disorder (MDD) and is withdrawn and quiet. Which of the following actions should the nurse take?
A. Leave the client alone in the room
B. Silently observe the client’s behavior
C. Provide the client with false reassurance
D. Use descriptive words when addressing the client
A nurse is reinforcing teaching with the partner of a client who has conversion disorder. Which of the following statements by the partner shows an understanding of the teaching?
A. “My partner is pretending to be ill to get attention.”
B. “My partner is purposely making our child sick.”
C. “The stress of losing our child caused my partner to go blind.”
D. “My partner is worried that he has cancer, even though his tests are normal.”
“The stress of losing our child caused my partner to go blind.”
*The nurse should explain to the partner that conversion disorder manifests as deficits in motor or sensory functions. Emotional conflict or stress is reflected in physical manifestations that can include paralysis, blindness, movement disorder, numbness, paresthesia, loss of hearing, or episodes resembling epilepsy
Potassium 2.9 mEq/L
*When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is potassium level of 2.9 mEq/L. The expected reference range for potassium is 3.5-5 mEq/L, with critical levels of less than 3 or greater that 6.1 mEq/L. A client who has a critical level of potassium is at great risk for cardiac dysrhythmias
A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect?
A. “I pick my face when I am nervous.”
B. “I have bald patches from pulling out my hair.”
C. “I inspect my body in the mirror several times a day.”
D. “I am unable to part with any of my belongings.”
Fever
*When using the urgent vs non-urgent approach to client care, the nurse should recognize that the priority adverse effect that should be reported to the provider when taking haloperidol is flu-like manifestations such as fever, a sore throat, fatigue, and muscle stiffness. These manifestations may indicate neuroleptic malignant syndrome, which is a life-threatening reaction to some antipsychotic medications
A nurse is reinforcing teaching with a client who has ADHD and a new prescription for a transdermal methylphenidate patch. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will rotate placing the patch on different parts of my upper body.”
B. “I can take showers with the patch in place.”
C. “If the patch bothers my skin, I will switch to the oral form of the medication.”
D. “I will apply a patch each night at bedtime.”
A nurse is caring for a client with schizophrenia who started taking a first-generation antipsychotic medication 3 weeks ago. The client reports a feeling of inner restlessness, rocks back and forth when sitting down, and paces frequently. The nurse should identify that the client is experiencing which of the following adverse effects of antipsychotic medications?
A. Neuroleptic malignant syndrome
B. Akathisia
C. Anticholinergic toxicity
D. Opisthotonos
Akathisia
*Akathisia is an extrapyramidal adverse effect that occur in a client within the first 2 months after beginning a first-generation antipsychotic medication. The client might be unable to rest due to a feeling of inner restlessness. Rocking back and forth and pacing the floor can also be manifestations of akathisia. The nurse should report this finding to the provider. Several medications such as propranolol can be used to treat akathisia
A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The client states, “This medication isn’t working. I want to stop taking it.” Which of the following responses should the nurse make?
A. “It is best to discontinue the medication slowly over 1 or 2 months.”
B. “If the medication hasn’t helped you in 3 months, it’s not going to.”
C. “You will likely gain weight if you stop taking the medication.”
D. “This medication is the only treatment for your condition.”
A nurse delegates a newly licensed nurse to provide one-on-one observation for a client who requires suicide precautions. Which of the following actions by the newly licensed nurse indicates the need for further reinforcement of teaching?
A. Accompanies the client to physical and occupational therapy
B. Ambulates the client’s roommate while the client sleeps
C. Asks the nurse at lunch time to assign another newly licensed nurse to perform this task
D. Remains with the client while family members are visiting
A nurse is performing a neurological examination for a client. To collect data about a client’s level of attention, the nurse should do which of the following?
A. Point to 2 objects and ask the client to name them
B. Ask the client to name the months of the year in reverse
C. Say 3 words and ask the client to repeat them
D. Ask the client to write a sentence
A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the client’s risk of which of the following adverse effects?
A. Increased intracranial pressure
B. Serotonin syndrome
C. Acute kidney injury
D. Hypertensive crisis
Serotonin syndrome
*Serotonin syndrome is a toxic effect that can occur from taking an MAOI such as tranylcypromine and an SSRI such as sertraline simultaneously. Manifestations include delirium, abdominal pain, muscle spasms, and irritability; these can worsen to cause cardiovascular shock and death. The nurse should notify the provider immediately of this potential interaction
A nurse at a long term care facility notes that a client with dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client’s level of orientation?
A. Encourage the client to make choices about meals and activities
B. Use written signs to label specific rooms
C. Post a large calendar on the bulletin board
D. Place a wander alert electronic alarm bracelet on the client’s wrist
A nurse is reinforcing teaching with a client about cannabis use disorder. Which of the following client statements indicates an understanding of the teaching?
A. “Withdrawal of cannabis occurs 3 days after cessation.”
B. “There are no physical manifestation of withdrawal from cannabis.”
C. “Drug screens can detect cannabis for up to 8 weeks after use.”
D. “Cannabis use can produce effects resembling the effects of alcohol use.”
“Cannabis use can produce effects resembling the effects of alcohol use.”
*The nurse should explain to the client that, when used moderately, cannabis produces effects resembling the effects of alcohol and other CNS depressants. By depressing higher brain centers, CNS depressants release lower centers from inhibitory influences
A nurse in a mental health facility is meeting with a client who has a diagnosis of major depression. During the conversation, the client stops speaking, and the nurse sits silently next to the client for several minutes. The nurse should identify that the therapeutic communication technique of silence is used for which of the following purposes?
A. To show approval of the client’s desire not to talk
B. To give the client time to evaluate the nurse
C. To encourage the client to express feelings or concerns
D. To prevent the nurse from offering a nontherapeutic response
To encourage the client to express feelings or concerns
*Silence during therapeutic communication has many functions, including providing clients with time to formulate their thoughts and encouraging the expression of feelings or concerns that they wish to discuss. During silence, the client can also consider alternatives and think about what has been said
A nurse is caring for a client who has obsessive-compulsive disorder and feels that pacing the floor for a specific number of times is necessary or else “something bad will happen.” Which of the following responses should the nurse provide?
A. “Nothing terrible is going to happen to you. Please stop this behavior.”
B. “Are you seeking attention with this behavior?”
C. “It may help if we talked about why you find it necessary to pace the floor.”
D. “Are you pacing to work off excess energy?”
A nurse in a rehabilitation center is collecting data from a client who is being admitted for alcohol use disorder. The client states, “My last drink was 8 hours ago.” Which of the following manifestation indicates that the client is experiencing withdrawal from alcohol?
A. Sleepiness
B. Tremors
C. Hypothermia
D. Diarrhea
Tremors
*A client who has alcohol use disorder can experience manifestations of withdrawal within 6 to 8 hours following their last drink. The classic sign of withdrawal is mild tremors. Other manifestations of withdrawal agitation, lack of appetite, nausea, insomnia, impaired cognition, hypertension, tachycardia, and hyperthermia
A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse provide?
A. “You should focus on getting better right now.”
B. “Why do you think you’ll be hospitalized for a long time?”
C. “All of your needs will be taken care of while you are in the hospital.”
D. “Tell me what concerns you most about being hospitalized.”
“Tell me what concerns you most about being hospitalized.”
*Clients with borderline personality disorder have a difficult time identifying their feelings. This response uses open0ended therapeutic communication, which allows the client to focus on concerns about hospitalization and encourages verbalization of feelings
A nurse is caring for a client who has bipolar disorder and is experiencing hypomania. During a conversation with other clients, she becomes agitated and begins speaking in a loud, angry voice. Which of the following actions should the nurse take?
A. Invite the client to take a walk
B. Reprimand the client for her rude behavior
C. Point out inappropriate behaviors to the client
D. Administer trazodone to the client
A nurse on a mental health unit is planning care for a client who has anorexia nervosa with purging behaviors. Which of the following interventions should the nurse include in the plan?
A. Set the client’s weight gain at 2.3 kg (5 lb) per week
B. Allow the client to establish his own mealtimes
C. Stay with the client for 1 hour following meals
D. Have the client weigh himself daily
A nurse is providing discharge teaching to the parent of an adolescent client who has bulimia nervosa and has been hospitalized for several weeks. Which of the following statements should the nurse identify as an indication that the parent understands the teaching?
A. “I should allow my child to make independent decisions.”
B. “I should give my child a laxative every evening.”
C. “I should make sure my child takes an antipsychotic medication several times daily.”
D. “I should discourage my child from exercising.”
Depression
*A client who has a stimulant use disorder and is experiencing withdrawal can experience depression. Other manifestations of stimulant withdrawal can include fatigue, paranoia, craving for stimulants, anxiety, increased appetite, poor concentration, hypersomnia or insomnia, and irritability
A nurse in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse, “Can I vote in the upcoming presidential election?” Which of the following responses should the nurse make?
A. “Why do you want to vote while you are in the hospital?”
B. “I wouldn’t worry about voting right now.”
C. “We can work together to find out how you can get a mail-in ballot.”
D. “You’ll have a lot more opportunities to vote after you get better.”
A nurse is having a conversation with a newly admitted client when the client suddenly stops talking. Which of the following statements should the nurse make?
A. “Apparently, you no longer wish to talk with me. Have I done something to make you angry?”
B. “I’ve noticed you have become quiet. Share with me what you are thinking when you are ready.”
C. “It is okay if you don’t wish to talk anymore right now. We can meet again tomorrow.”
D. “You need to talk during this time I have set aside for you. Talking is what will get you out of here.”
A home health nurse is reinforcing teaching with the caregiver of a client who has Alzheimer’s disease. Which of the following instructions should the nurse provide?
A. Have the client wear a medical alert necklace
B. Place written signs on the bathroom and other doors in the house
C. Prevent the client from taking naps during the day
D. Provide a low stimulation environment
Positive
*The nurse should identify a client who has schizophrenia and is experiencing delusions is demonstrating a positive symptom. Positive symptoms are seen early in clients who have schizophrenia and are easier to detect that other types of symptoms. Other positive symptoms can include hallucinations, disorganized speech, and disorganized behavior
A nurse is helping a client who has anxiety disorder select a nonpharmacological stress-reduction therapy for home use. Which of the following therapies engages the insular cortex of the brain to allow the client to focus on a single thought that is important to the client in the present moment?
A. Guided imagery
B. Progressive relaxation
C. Cognitive reframing
D. Mindfulness
Mindfulness
*The practice of mindfulness engages the insular cortex as the person focuses on the sensations and surroundings of the present moment. The client learns to stop the mind from wandering to multiple thoughts and worries and to concentrate on a single thought or situation that is important at that time
A nurse is reinforcing teaching with a client who has generalized anxiety disorder to perform a deep-breathing exercise. Which of the following actions should the nurse instruct the client to take?
A. Utilize chest breathing
B. Breathe in through the nose
C. Keep the shoulder erect
D. Repeat the exercise for at least 10 minutes for effectiveness
A nurse is interviewing a client whose partner died 6 months ago. The client states, “I feel so lonely and empty inside.” Which of the following responses should the nurse make?
A. “I know how you feel.”
B. “Have you thought about remarrying?”
C. “This loss must be tragic for you.”
D. “Your partner is in a better place now.”
A nurse is caring for a client with bipolar disorder who is experiencing a manic episode. Which of the following actions should the nurse take?
A. Discourage the client from taking naps during the day
B. Allow the client to choose which items of clothing to wear each day
C. Encourage the client to participate in group therapy
D. Provide high-calorie finger-foods frequently
Provide high-calorie finger-foods frequently
*The nurse should offer the client frequent high-calorie snacks and meals during a manic episode to provide the calorie replacement needed due to excessive physical energy and activity. Providing finger-foods increases the client’s intake when mania makes sitting down and concentrating on a meal
A nurse in a provider’s office is collecting data on a client who is taking paroxetine for the treatment of social anxiety. Which of the following information from the client should the nurse reports to the provider immediately?
A. The client reports a change in appetite
B. The client is experiencing insomnia
C. The client reports being depressed
D. The client is experiencing headaches
A nurse on a mental health unit is caring for a group of clients. Which of the following is an example of a client using the defense mechanism of rationalization?
A. A client who take opioids several times daily but refuses to admit she has a substance use disorder
B. A client who bullies her partner because she is ridiculed at work
C. A client who was physically abused as a child and cannot remember the events
D. A client who states he drinks alcohol to excess because his marriage is failing
A nurse is caring for a client who is showing evidence of addiction to pain medication prescribed for rheumatoid arthritis. When questioned about the usage of the medication, the client states, “It is not an illegal drug.” Which of the following defense mechanisms is the client using?
A. Displacement
B. Rationalization
C. Projection
D. Sublimation
A nurse is reviewing discipline techniques with the parents of an adolescent client who has oppositional defiant disorder. Which of the following techniques should the nurse recommend as an effective method of responding to the adolescent?
A. Offering frequent physical touching
B. Allowing self-regulation of boundaries
C. Practicing planned ignoring
D. Giving negative feedback
A nurse working in a retirement community is collecting data from an adult client. Which of the following findings should cause the nurse to suspect the client is experiencing the early stages of Alzheimer’s disease?
A. Requiring help to record a television show
B. Misplacing a family heirloom
C. Feeling tired after a social gathering
D. Completing tasks in a particular way
A nurse is observing a client who has histrionic personality disorder. Which of the following behaviors should the nurse expect?
A. The client whispers in the provider’s ear
B. The client refuses to provide her telephone number
C. The client has diminished facial expressions
D. The client asks if she is doing the right thing 3 times during the appointment
A newly admitted client who has major depressive disorder states to the nurse, “I’m a failure. I can’t even cope with little things anymore.” Which of the following responses should the nurse make?
A. “What happened in your life to make you feel like such a failure?”
B. “You sound like you’re feeling pretty overwhelmed right now.”
C. “Do you feel like you don’t deserve to be good to yourself?”
D. “I know you feel like that now, but you’ll feel differently when you get better.”
A nurse is caring for a client who has conduct disorder and is displaying violent behavior. After several attempts to provide a diversion, the nurse applies a physical restraint. Which of the following actions should the nurse take?
A. Check the client’s physical needs every 30 minutes
B. Obtain the client’s vital signs once per shift
C. Tie the restraint to the side rail of the client’s bed
D. Use square knots to secure the client’s restraint
Check the client’s physical needs every 30 minutes
*While the client is in restraints, the nurse should check the client’s physical needs every 30 minutes. The nurse should offer food and hydration and should allow the client to use the bathroom if necessary. The nurse should also document these findings
A nurse in an outpatient facility is assessing a 3-month-old infant who has lost weight and has injuries that indicate physical abuse. When preparing to interview the parent, which of the following actions should the nurse plan to take?
A. Insist that the parent tell the nurse how the child was injured
B. Tell the parent that a child protective agency must be notified
C. Show disapproval to the parent regarding the infant’s condition
D. Call at least 2 other staff members to sit in the room during the interview
A nurse is reinforcing teaching with a client who has acrophobia about the use of systemic desensitization as a method of behavioral therapy. Which of the following client statements indicates an understanding of the teaching?
A. “I will snap a rubber band on my wrist when heights scare me.”
B. “I will slowly be exposed to places of increasing height.”
C. “I will need to stand on a very high place until I’m calm.”
D. “I will be asked to imitate how my therapist acts around heights.”
“I will slowly be exposed to places of increasing height.”
*This statement indicates client understanding of systematic desensitization. This form of behavioral therapy gradually exposes the client to frightening places or situations and teaches the client to overcome the fear through the use of relaxation techniques
A nurse is communicating with a newly admitted client. Which of the following rationales identifies the nurse’s purpose for using therapeutic communication with the client?
A. Therapeutic communication identifies and analyzes the client’s problems
B. Therapeutic communication builds a relationship that will allow expression of mutual concerns
C. Therapeutic communication provides a foundation for the client’s relationship with the provider
D. Therapeutic communication ensures the client will remain cooperative with care in the facility
A nurse is assisting a client whose house was just destroyed by a fire. Which of the following actions should the nurse take?
A. Assist the client in identifying resources
B. Give the client a time frame in which to find shelter
C. Assure the client that everything will work out
D. Encourage the client to focus on actions and not emotions
A nurse in an acute mental health facility is participating in a nursing staff discussion about the legal aspects of involuntary admissions. Which of the following pieces of information should the nurse include?
A. A client who is involuntarily admitted must take prescribed medications
B. An involuntary admission of a client is limited to 2 weeks
C. A client who is involuntarily admitted can leave the facility against medical advice
D. An involuntary admission is justified if the client is a danger to others
A nurse is planning care for a newly admitted client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse recommend for this client?
A. Rotate staff assignments for the client
B. Refrain from discussing the client’s maladaptive coping strategies
C. Wait for the client to initiate interactions with staff members
D. Encourage the client to participate in group therapy
A client who has cognitive impairment tells the nurse, “I’m leaving now. I have to be home by 5:00 PM because dinner will be ready.” Which of the following responses by the nurse demonstrates the use of validation therapy?
A. “It it 5:30 PM now. You are in the hospital and we will bring you dinner soon.”
B. “Don’t worry about dinner. Your father is bringing dinner here for you tonight.”
C. “At home, you had dinner at 5:00 PM. Was your father a good cook?”
D. “Your father was born around the year 1920. Can you tell me what year it is now?”
“At home, you had dinner at 5:00 PM. Was your father a good cook?”
*This response validates the client’s feelings and redirects the conversation to another topic so that the client can talk about personal memories. Validation therapy does not attempt to orient the client to reality but instead recognizes the underlying feelings expressed by the client and then redirects the conversation
A nurse in the emergency department is assessing a client who has generalized anxiety disorder. Which of the following actions should the nurse take first?
A. Instruct the client to use guided imagery
B. Move the client to a quiet area
C. Assist the client in identifying his coping skills
D. Allow the client time to express his feelings
A nurse is contributing to the plan of care for a group of clients. Which of the following interventions is the priority for the nurse to include?
A. Offer high-calorie beverages to a client who is in the manic phase of bipolar disorder
B. Practice relaxation techniques with a client who has anxiety disorder
C. Assist a client who has depressive disorder with decision-making regarding group activities
D. Reinforcing teaching to a client who has schizophrenia about a new prescription for clozapine
A nurse is caring for a client who has bipolar disorder. After the client is prescribed lithium, his adult child states, “I’m upset that my father is taking this medication.” Which of the following responses should the nurse make?
A. “It will be alright. You father’s provider knows what she is doing.”
B. “You should be more concerned about your father’s mania, which puts him at risk for injury.”
C. “Tell me what worries you have about your father taking this medication.”
D. “This is an important medication that will treat your father’s condition.”
A nurse is assisting with the planning of a staff education session about the administration of antidepressant medications to older adult clients. Which of the following pieces of information should the nurse recommend including?
A. Older adult clients require a lower initial dose of antidepressant medication than adult clients
B. Older adult client should not receive antidepressant medication
C. Older adult clients achieve the therapeutic effects of antidepressant medications more quickly than adult clients
D. Older adult clients have a decreased risk of adverse effects from antidepressant medication
A nurse in a mental health unit is contributing to the plan of care for a client who is receiving treatment for self-inflicted injuries. Which of the following interventions is the priority for this client?
A. Promoting and maintaining client safety
B. Discussing reasons for the client’s behavior
C. Helping the client recognize feelings
D. Reinforcing teaching with the client about alternative coping strategies
A nurse is assisting with the admission of a client to an acute-care mental health facility following a suicide attempt. Which of the following actions should the nurse take first?
A. Assess the client’s level of self-esteem
B. Document the client’s mood and affect
C. Attend an interdisciplinary team meeting
D. Search the client’s belongings
Hypertension
*The nurse should identify that hypertension is a manifestation of opioid withdrawal. Other manifestations of opioid withdrawal can include tachycardia, enlarged pupils, increased body temperature, tachypnea, diaphoresis, rhinorrhea, anxiety, muscle spasms, nausea and vomiting, and abdominal cramping
A nurse is caring for a client who has borderline personality disorder (BPD). The client states, “You are the best nurse. All of the other nurses are mean.” The nurse should identify that the client is demonstrating which of the following manifestations of BPD?
A. Impulsivity
B. Clinging
C. Splitting
D. Manipulation
A nurse is reinforcing teaching with a client who has agoraphobia about systemic desensitization. Which of the following comments should the nurse include in the teaching?
A. “You will watch from a secure location as your therapist goes to public spaces.”
B. “You will start your therapy by staying in a public space until your anxiety decreases.”
C. “You will be instructed to say “Stop!” out loud when you become anxious in public spaces.”
D. “You will slowly be exposed to increasing levels of public spaces.”
A nurse in an assisted living facility is collecting data on an older adult client. Which of the following findings should the nurse identify as expected age-related changes?
A. Forgetting the days of the week
B. Challenges with problem-solving
C. Decreased judgment
D. Withdrawal from social activities
Forgetting the days of the week
*The nurse should identify that forgetting the day of the week and remembering it later is an expected age-related change in older adult clients. Other findings can include needing assistance when operating devices such as a microwave, making occasional errors when balancing a checkbook, having difficulty finding the correct use of a word, and becoming tired after family gatherings or social activities
A nurse is reinforcing teaching with a client who recently completed detoxification from alcohol and has a new prescription for acamprosate. Which of the following statements should the nurse make?
A. “You will get very sick if you drink alcohol while taking this medicaion.
B. “The medication will be administered as a subcutaneous injection.”
C. “You should take this medication on an empty stomach.”
D. “The medication might cause you to have episodes of diarrhea.”
A nurse is reinforcing teaching with a client who is scheduled for electroconvulsive therapy (ECT) to treat major depression. Which of the following pieces of information should the nurse include?
A. “You will be awake during the procedure.”
B. “You will experience a seizure during this procedure.”
C. “You can’t eat or drink anything for 24 hours before the procedure.”
D. “You are not required to sign an informed consent form for this procedure.”
“You will experience a seizure during this procedure.”
*The nurse should inform the client that the procedure will involve a seizure. ECT induces a generalized seizure of the brain by electrical current. ECT increases neurotransmitters in the brain, which can assist with treating the client’s depression
Drowsiness
*The nurse should be aware that alprazolam, a benzodiazepine, commonly causes CNS depression, including drowsiness. When administering this medication to a client for the first time, the nurse should monitor the client for drowsiness and implement interventions to reduce the risk of falls or injury
Phenelzine
*Phenelzine is a monoamine oxidase inhibitor that is prescribed for depression and other mental health disorders. An adverse effect of phenelzine is orthostatic hypotension. The nurse should inform the client who is taking phenelzine that dizziness an lightheadedness are indications of hypotension. The nurse should also instruct the client to rise slowly from a side-lying or sitting position to minimize a drop in blood pressre
A nurse is assisting with the admission of a client who has tetraplegia. The nurse notes multiple bruises on the client and suspects abuse. Which of the following actions should the nurse take?
A. Interview the client with the caregiver present
B. Inform the provider that the caregiver is to blame for the abuse
C. Begin the interview with simple close-ended questions
D. Inform the client that nurses are required to notify protective services
A home health nurse is speaking with the caregiver of a client who has Alzheimer’s disease. The caregiver asks the nurse why the client becomes disoriented, confused, and often combative later in the day. For which of the following conditions should the nurse plan to gather more information?
A. Electrolyte imbalance
B. Hypothyroidism
C. Sundowning
D. Adverse effect of medication
A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective?
A. Dullness with chest percussion
B. Heart rate 118/min
C. Conjunctival discharge
D. Respiratory rate 28/min
A nurse is caring for a client who has bipolar disorder. The client states, “My family wants me to come home for a visit. What do you think I should do?” Which of the following responses should the nurse make?
A. “Tell me how you are feeling about their request.”
B. “I think spending some time with your family is important.”
C. “Maybe you shouldn’t go if you’re not sure about the visit.”
D. “What does your social worker think you should do?”
A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions is the nurse’s priority?
A. Ask the client what the voices are saying
B. Focus the client’s attention on reality-based activities
C. Make eye contact when speaking with the client
D. Encourage the client to listen to music through headphones
A nurse is reinforcing teaching with the guardian of a client who has bipolar disorder and a new prescription for olanzapine. Which of the following adverse effects should the nurse instruct the guardian to report to the provider?
A. Hypertension
B. Tremors
C. Ringing in the ears
D. Pain with urination
Tremors
*Olanzapine can cause extrapyramidal symptoms (EPS). The nurse should reinforce with the guardian to report manifestations indicating the development of EPS such as bradykinesia, mask-like facies, tremors, rigidity, a shuffling gait, drooling, stopped posture, or spasm of the muscles of the tongue, face, neck, or back
A nurse is reinforcing teaching with the partner of a client who is at risk for alcohol withdrawal after 6 hours of cessation. Which of the following statements by the partner indicates an understanding of the teaching?
A. “My partner might experience seizures after 3 days of abstinence.”
B. “Delirium tremens generally occurs within 24 hours.”
C. “Hypotension is a manifestation of alcohol withdrawal.”
D. “My partner might begin to shake.”
Muscle spasms
*Muscle spasms are a manifestation of opioid withdrawal
A nurse is admitting a client who has derealization disorder. Which of the following manifestations should the nurse expect?
A. The inability to recall important personal information
B. The feeling that the surroundings are unreal
C. The inability to recall identity
D. The presence of at least 2 distinct personalities
The feeling that the surroundings are unreal
*The feeling that the surroundings are unreal or distant is a manifestation of derealization disorder. Clients who have this disorder might feel mechanical, dreamy, or detached from their body. Often, the manifestations are destressing and come and go. The disorder occurs as a response to acute stress
A nurse is reinforcing teaching with the family of a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements made by a family member indicates an understanding of ECT?
A. “We are so glad there are no physical side effects of shock treatment.”
B. “Thank goodness there is no permanent memory loss.”
C. “Cardiac dysrhythmias can persist for several weeks.”
D. “We won’t be alarmed if there is some confusion after the treatment.”
A nurse is reinforcing teaching with a client who has a prescription for lithium. Which of the following instructions should the nurse include in the teaching?
A. Take this medication on an empty stomach
B. Drink 2 L of fluid each day
C. Use a salt substitute to season foods
D. Take ibuprofen for headaches
A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse take first?
A. Apply mechanical restraints to the client
B. Administer PRN haloperidol IM to the client
C. Approach the client in a nonthreatening manner
D. Place the client in seclusion
A nurse on a psychiatric unit is talking with a client who makes a sexual advance toward the nurse. Which of the following responses should the nurse provide?
A. “It’s normal for you to have sexual feelings toward the staff.”
B. “You need to stop any type of sexual advances.”
C. “This behavior is unacceptable while I am your nurse.”
D. “What would your family think of this type of behavior?”
A nurse is assisting with the admission of a client who has alcohol use disorder and is experiencing withdrawal. Which of the following actions is the nurse’s priority?
A. Pad the side rails of the client’s bed
B. Assign the client to a private room
C. Collect a urine sample from the client
D. Determine the client’s level of disorientation
A nurse is caring for a client who has schizophrenia and is becoming anxious due to auditory hallucinations. Which of the following actions should the nurse take?
A. Offer the client therapeutic touch
B. Ask the client what he is hearing
C. Affirm the presence of the voices
D. Move the client into a more stimulating environment
Ask the client what he is hearing
*The nurse should ask the client about what he is hearing to determine if the hallucination is causing fear or distress to the client. Also, the nurse needs to determine if the hallucination may cause the client to harm himself or others. However, asking the client, “What are the voices saying to you?” can infer that the nurse believes the voices are real
A nurse is speaking with parents who are at a clinic for a 2-week follow-up visit after the birth of their second child. They report that their 5-year-old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the parents that this is expected behavior and illustrates which of the following defense mechanisms?
A. Compensation
B. Repression
C. Regression
D. Suppression
Regression
*Regression is reverting to a previous, more child-like behavior
A nurse is caring for a client who has a repetitive tic that is accompanied by rapid blinking. The client occasionally repeats phrases spoken by others. The nurse should identify that these findings are an indication of which of the following disorders?
A. Autism spectrum disorder
B. Attention deficit hyperactivity disorder
C. Oppositional defiant disorder
D. Tourette’s disorder
A nurse is caring for a client who has antisocial personality disorder. The client uses manipulation to gain access to a smoking area from which his access has been limited as a behavioral intervention. Which of the following statements should the nurse make?
A. “You know you shouldn’t use the smoking area.”
B. “You know that manipulation is not the right thing to do.”
C. “Let’s review the consequences of your actions.”
D. “I can talk with the provider about reducing your smoking restriction.”
“Let’s review the consequences of your actions.”
*When communicating with a client who has antisocial personality disorder, the nurse should set clear and realistic limits on behavior that all staff members adhere to, identify the client’s undesirable behavior, and communicate the consequences of that behavior
A nurse is caring for a client who was voluntarily admitted to an inpatient mental health facility for treatment of major depressive disorder. After consenting to deep brain stimulation, the client tells the nurse he does not want to have the procedure. Which of the following actions should the nurse take?
A. Explain that the provider is highly proficient in this therapy
B. Tell the client that he has the right to refuse the procedure
C. Explain that deep brain stimulation is a promising therapy for major depression
D. Remind the client that agreeing to admission means the provider can proceed with the treatment
A nurse is collecting data from a client who has been using a nicotine transdermal patch for smoking cessation. The client reports itching of the skin where the patch is applied. Which of the following statements should the nurse make?
A. “You should change the location of the patch on your body.”
B. “Decreasing the strength of the patch should stop the itching.”
C. “You should discontinue using the patch.”
D. “This is an adverse effect of the patch that will subside in time.”
A nurse is collecting data from an adult client whose sister recently died in a motor vehicle crash. The nurse should identify that which of the following factors indicates an increased risk for a complicated grief reaction?
A. The loss of a sibling
B. The perception that the death was unavoidable
C. The sudden occurrence of the death
D. The presence of a social support network
A nurse is collecting data from a client who has major depressive disorder regarding suicide risk factors and protective factors. Which of the following client statements should the nurse identify as a protective factor that decreases the client’s risk for suicide?
A. “I am a college graduate and make a lot of money at my profession.”
B. “I consider myself a good problem solver.”
C. “My family lives out-of-state, and I spend my spare time at home.”
D. “I enjoy restoring antique weapons and have a nice collection.”
A nurse is reinforcing teaching with a client who has a new prescription for buspirone to treat anxiety. Which of the following statements should the nurse include in the teaching?
A. “Use buspirone with caution because it raises the risk of suicidal thoughts.”
B. “You can minimize adverse effects by taking buspirone with grapefruit juice.”
C. “Buspirone enhances the depressant effects of alcohol.”
D. “Buspirone causes nausea in some people.”
A nurse in a long-term mental health facility is caring for a client who has a personality disorder. Because the client has broken a unit rule, phone privileges are being revoked. The client asks the nurse, “Can’t I just make another phone call?” Which of the following responses should the nurse make?
A. “No, you can’t. Go sit in your room.”
B. “Okay, if you promise to obey the rules for the rest of the day.”
C. “No, you can’t. You have broken the rules that apply to everyone.”
D. “You can make only a 5-minute phone call.”
A nurse is caring for a newly admitted client who is receiving treatment for alcohol use disorder. The client tells the nurse, “I have not had anything to drink for 6 hours.” Which of the following findings should the nurse expect during alcohol withdrawal?
A. Low body temperature
B. Insomnia
C. Muscle flaccidity
D. Bradycardia
A home health nurse is reinforcing teaching for the family who has moderate Alzheimer’s disease. The family plans to care for the client in their home. Which of the following recommendations should the nurse include in the teaching?
A. Place nonskid throw rugs over smooth surface floors
B. Install locks at the top of exterior doors
C. Provide clothing that has zippers instead of buttons
D. Encourage frequent naps during the day
Install locks at the top of exterior doors
*This client is at an increased risk of wandering and getting lost. A safety intervention to decrease the risk of wandering is to install locks at the tops of exterior doors since a client who has moderate Alzheimer’s disease loses the ability to reach and look upward
A nurse in a community urgent care facility is helping plan interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching?
A. Determine if the client is experiencing thoughts of self-harm
B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available
C. Encourage the client to shower before undergoing a physical examination
D. Assess the client for the presence of a maturational crisis
A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurse’s priority?
A. Maintain the client’s contact with her family
B. Discourage the client’s use of vulgar language
C. Protect the client from impulsive behavior
D. Redirect excessive energy to creative tasks
A nurse is talking with a client who has anxiety disorder. The client states, “I have something important to tell you, but you have to promise to keep it a secret.” Which of the following responses should the nurse make?
A. “Anything you tell me is kept private between us.”
B. “I feel uncomfortable being asked to keep a secret for you.”
C. “Why do you feel that the information needs to be kept private?”
D. “I might have to share the information with your provider.”
“I might have to share the information with your provider.”
*The nurse should be honest with the client so that the client can decide whether to share the information. The information the client shares can be vital for the treatment plan and can present a safety risk for the client or others. Therefore, the nurse might be legally obligated to share the information with the client’s provider and health care team
A nurse is assisting with planning an in-service session about involuntarily commitment to mental health facilities for a group of newly licensed nurses. Which of the following pieces of information should the nurse recommend including?
A. The client can challenge hospitalization following emergency treatment
B. Involuntarily commitment requires the hospitalization of the client
C. A client who is competent but committed involuntarily is unable to make treatment decisions
D. Court hearings should be held 7 days after emergency commitment
Involuntarily commitment requires the hospitalization of the client
*A client can be court-ordered to undergo outpatient psychiatric treatment as well as inpatient treatment. Involuntary outpatient treatment is used most often for clients who have severe and chronic mental illness in order to limit the need for inpatient admissions for the client
Ascites
*The nurse should expect this client who has cirrhosis of the liver to exhibit gastrointestinal and hepatic manifestations due to the destruction of liver cells. Ascites results from the accumulation of serous fluid in the abdominal cavity due to portal hypertension. Jaundice, weight loss, and esophageal varices are other expected findings of this disorder
A nurse in a mental health clinic is working with a client whose partner recently started working overseas. The client states, “My youngest child is having difficulty coping with my partner’s absence.” Which of the following responses should the nurse offer?
A. “You should administer punishment if your child acts out.”
B. “Continue to do the activities that your family did before your partner’s absence.”
C. “You child should see a counselor if he doesn’t adjust to your partner’s absence within 2 weeks.”
D. “Give your child the opportunity to spend as much time alone as he needs”
“Continue to do the activities that your family did before your partner’s absence.”
*The nurse should instruct the client to continue usually family activities from before the partner’s absence and to encourage the child to resume his usual activities. Returning to familiar activities can help re-establish a sense of normalcy for the family
A nurse is planning care for a newly admitted child who has autism spectrum disorder. Which of the following actions should the nurse nurse include in the plan of care?
A. Avoid making eye contact with the child
B. Rotate staff assignments for the child
C. Offer frequent acts of physical affection towards the child
D. Give the child a favorite toy to hold
A nurse is assisting with the collection of admission data for a client who has anorexia nervosa. The client has lost 11.4 kg (25 lb) over the past month and currently weights 38.6 kg (85 lb). The nurse should expect which of the following findings?
A. Flushed extremities
B. Hyperkalemia
C. Loose stools
D. Amenorrhea
A client who has hypertension presents to a provider’s office. When speaking with the nurse, she reports a considerable amount of stress at work and states it is affecting her blood-pressure control. The nurse should instruct the client to do which of the following when the stress is unavoidable?
A. Consider changing jobs to something less stressful
B. Identify the stressors at work and try to reduce them
C. Plan periods away from work throughout the day
D. Improve her ability to cope with identified stressors
A nurse is caring for a client who is confused and wanders at night. The nurse asks the charge nurse if the client can be placed in physical restraints at bedtime. Which of the following responses should the charge nurse provide?
A. “Restraints can be used if the client is having verbal outbursts.”
B. “Restraints have been effective in reducing the number of client falls.”
C. “Restraints can used only when the unit manager approves.”
D. “Restraining the client can increase confusion.”
A nurse is caring for a client who has schizophrenia. The client states, “Aliens came into my room last night and took a sample of my blood.” Which of the following responses should the nurse make?
A. “Aliens do not exist.”
B. “Has your daughter had her baby?”
C. “Do you mean to say a laboratory technician drew your blood last night?”
D. “That does not sound real.”
“That does not sound real.”
*The nurse is voicing doubt with this response, which expresses uncertainty regarding the reality of the client’s conclusion of the hallucination. This is a therapeutic response because the statement allows the client to expand upon the earlier statement, which allows exploration of the client’s thought processes
A nurse is reinforcing discharge teaching with the guardians of an adolescent who has bipolar disorder. Which of the following manifestations should the nurse identify as an indication of acute mania? (select all that apply)
A. Complete school projects
B. Naps during the daytime
C. Eats large amounts
D. Spends excessive amounts of money
E. Speaks using a loud and crass voice
1. Spends excessive amounts of money
2. Speaks using a loud and crass voice
*A client who has acute mania is impulsive and at risk of spending excessive amounts of money despite financial status. Additionally, a client who has acute mania has rapid speech and quick thoughts; other alterations in speech include speech that is vulgar or sexually explicit
A nurse in a health clinic is reinforcing teaching with a client about binge eating disorder. Which of the following client statements indicates an understanding of the teaching?
A. “This problem is caused by a slow metabolism.”
B. “The abdominal pain I often have is due to the amount of food that I eat.”
C. “Most of my weight gain is water weight.”
D. “At least I do not need to worry about being physically ill.”
“The abdominal pain I often have is due to the amount of food that I eat.”
*Gastrointestinal complications can arise for clients who have binge eating disorder due to the larger than normal amount of food they consume. Other manifestations include constipation, diarrhea, urgency, and a feeling of anal blockage
A nurse is assisting a client who has major depressive disorder. The client states, “This has been the worst day of my life.” Which of the following responses should the nurse make?
A. “You should focus on positive things rather than negative things.”
B. “We all have a bad day from time to time.”
C. “Why would someone with so much to live for say that?”
D. “Please take a seat and talk to me about it.”
“Please take a seat and talk to me about it.”
*This response by the nurse is therapeutic and encourages the client to talk about his feelings and what might have caused them. This helps the nurse develop a trusting relationship with the client, in which the client will feel safe opening up to the nurse. Using therapeutic communication techniques helps to identify the client’s specific needs and problems, which can lead to a solution
A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client informs the nurse, “I do not want visitors today because I look and feel terrible.” Which of the following responses should the nurse make?
A. “That is silly. You look just fine to me.”
B. “Nobody expects you to look good in a hospital.”
C. “I understand. Would you like to wash your hair?”
D. “Would you like to talk about why you feel this way?”
A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include to address limit-setting?
A. Instruct the client to use reaction formation for behavior control
B. Recommend the client attend assertiveness training
C. Establish and explain consequences of the client’s behavior
D. Encourage the client to increase socialization
Establish and explain consequences of the client’s behavior
*The nurse should communicate desired behavior and expectations to the client, as well as the detailed consequences of not meeting them. When addressing limit-setting with the client, these expectations and consequences should be included in the plan of care
A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. These manifestations indicate which of the following adverse effects of haloperidol?
A. Akathisia
B. Acute dystonia
C. Tardive dyskinesia
D. Pseudoparkinsonism
Tardive dyskinesia
*The nurse should identify that tardive dyskinesia can be manifested by involuntary movement of many body parts. Early findings include writhing movements of the tongue and smacking of the lips. The nurse should report these findings to the provider immediately because they might not be reversible and can progress to affect all extremities with rhythmic, uncontrollable writhing movements
A nurse in a clinic is collecting data from a client who asks for help with depression. Which of the following questions is the nurse’s priority?
A. “Is there anything in particular that makes you feel angry?”
B. “Have you had difficulty falling asleep or staying asleep?”
C. “Have you thought about harming yourself in any way?”
D. “Do you have someone you can talk with at home?”
A nurse is discussing the benefits of group therapy with a client who has bipolar disorder. The nurse should identify which of the following as an advantage of this form of treatment?
A. Decreased pressure from others to engage in unacceptable behaviors
B. The chance to learn from the experiences of other individuals
C. An outlet for increased energy during episodes of mania
D. The opportunity to have increased participation time during therapy
A nurse is collecting data from a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent’s treatment team?
A. Calling family members
B. Spending time alone
C. Giving away possessions
D. Excessive crying
Giving away possessions
*Giving away possessions indicates that this adolescent client is a the greatest risk for suicide. The nurse should have a relationship built on trust an respect so that the nurse feels comfortable enough to ask the adolescent directly about suicidal thoughts and/or plans. Therefore, this is the priority finding for the nurse to report to the treatment team
A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of playing staff members against each other. Which of the following actions should the nurse take?
A. Have the same staff members work with the client on a long-term basis
B. Listen to the client when he reports feelings about other staff members
C. Explore the client’s use of clinging and distancing behaviors with him
D. Arrange for the client to share complaints with the nursing supervisor
Explore the client’s use of clinging and distancing behaviors with him
*Splitting is a common defense mechanism demonstrated by clients who have BPD in which the client plays staff members against each other. First, the client expresses feelings of attachment toward a certain staff member and then abruptly begins issuing complaints about this person to other staff members. The underlying cause of splitting is a fear of abandonment and an inability to accept both positive and negative feelings. Therefore, the client demonstrates only negative or positive feelings toward others
A nurse is caring for a client who has generalized anxiety disorder. The client states, “I am so stressed about my work and finances. I can’t think straight anymore.” Which of the following actions should the nurse take first?
A. Administer antianxiety medication
B. Speak slowly and calmly
C. Remain with the client
D. Ask the client to talk about preceding events
A nurse is participating with a disaster-support team following a tornado. When collecting data from a client who was affected by the tornado, which of the following questions should the nurse ask the client first?
A. “Do you feel safe now that the tornado is gone?”
B. “What do you think about the tornado?”
C. “Do you have anyone you can contact for support?”
D. “How do you usually cope with difficult situations?”
A client recently diagnosed with terminal cancer states to the nurse, “I wish I were dead. I have no reason to live.” Which of the following responses should the nurse offer?
A. “You still have a lot to live for.”
B. “Please don’t talk about that.”
C. “Your prescribed medication will make you feel better.”
D. “Have you been thinking of hurting yourself.”
“Have you been thinking of hurting yourself.”
*The nurse’s response focuses on the client’s underlying feelings and begins to examine the obvious verbal clues of suicidal thoughts. Asking the client about suicidal thoughts is an important intervention by the nurse because if the client is contemplating suicide, the client should be able to discuss these feelings with the nurse
A nurse is caring for a client who has newly diagnosed with breast cancer that has metastasized in to the spine. The client refuses to discuss treatment options. The nurse should identify that the client is experiencing which of the following stages of Kubler-Ross’ grief theory?
A. Anger
B. Bargaining
C. Denial
D. Depression
Denial
*During the first stage, denial and refusal to accept the imminence of the loss are self-protection mechanisms that allow the client to process the diagnosis. During this stage, the client has difficulty accepting the loss or diagnosis and might refuse to discuss the impending or actual loss during this stage. The client might also be convinced that a mistake has been made and that there is no loss
Anxiety
*The nurse should expect the client to have anxiety during opioid withdrawal
A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider?
A. Blurred vision
B. Urinary retention
C. Muscle flaccidity
D. Elevated temperature
Monitor the client for adverse effects of the medications.
Identify the client’s perception of her mental health status.
The client arouses briefly in response to a sternal rub.
A client who has borderline personality disorder and assaulted a homeless man with a metal rod
Report the incident to the health care team, but do not inform the client of the intention to do so.
Tell the nurse to stop discussing the behavior
I understand you’re concerned. Let’s discuss what concerns you specifically.”
A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client has a respiratory rate 30/min and says, “This is difficult to comprehend. I feel shaky and nervous.” The nurse should identify that the client is experiencing which of the following levels of anxiety?
-Losing someone close to you must be very upsetting.”
-It is goal-directed.
-Behavioral change is encouraged.
-A termination date is established.
The client accuses the nurses of telling him what to do just like his ex-girlfriend.
Discussing ways to use new behaviors
You and the other clients will meet with staff to discuss common problems.
A client who says he is hearing a voice that tells him he is not worth living anymore.
Establishing rehabilitation programs to decrease the effects of depression
-Educational groups
-Medication dispensing programs
-Individual counseling programs
-Family therapy
A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client’s wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow-up care?
Attending a partial hospitalization program
The therapist will focus on my past relationships during our sessions.”
I should say the first thing that comes to my mind.”
-Priority restructuring
-Monitoring thoughts
-Journal keeping
Gradually expose the client to an elevator while practicing relaxation techniques.
Observes group techniques without interfering with the group process
A nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he’s the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following?
A member who brags about accomplishments
Excessive stressors cause the client to experience distress.
A. Chronic pain
B. Depressed immune system
E. Unhappiness
Cognitive reframing will help me change my irrational thoughts to something positive.
I will receive a muscle relaxant to protect me from injury during ECT
“I will schedule the client for daily TMS treatments for the first several weeks.”
C. Memory loss
D. Nausea
E. Confusion
Bipolar disorder with rapid cycling
A. Voice changes
D. Dysphagia
E. Neck pain
Stay with the client and remain quiet
A. Excessive worry for 6 months
D. Restlessness
E. Need for reassurance
Assessing the client’s risk for self harm
Tell me about how you are feeling right now.”
A. Difficulty concentrating on tasks
C. Negative self-image
D. Recurring nightmares
The client expresses a sense of unreality about the traumatic event
The client states that the furniture in the room seems to be small and far away
Work with the client on grounding techniques
A nurse working in an acute mental health facility is caring for a 35-year-old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (Select all that apply)
A. Age
B. Gender
C. History of chronic asthma
E. Being married
Placing the client on one-to-one observation
I am aware that my PMDD causes me to have rapid mood swings.”
The client is at greatest risk for suicide during the first weeks of an MDD episode.
Presence of manifestations for at least 2 years
B. Offer concise explanations
C. Establish consistent limits
E. Use a firm approach with communication
“ECT is effective for client’s who are experiencing severe mania.”‘
I am here to provide care and cannot accept this from you”
Monitor the client for escalating behavior
A. Auditory hallucination
C. Use of clang association
D. Delusion of persecution.
I am no one, and everyone is me.”
Initiate one-to-one observation of the client
Ask the client, “Are you seeing something on the ceiling?”
I should practice limit-setting to help prevent client manipulation.”
I’m scared that you’re going to leave me.
You can expect the progression of cognitive decline to slow with donepezil.”
I am your nurse. Let’s walk together to your room.”
Provide information on resources for respite care.
B. Family report of personality changes
C. Hallucinations
E. Restlessness
Older adults are at an increased risk for substance use following retirement.
B. Fine tremors of both hands
D. Vomiting
E. Restlessness
Implement seizure precautions.
Life isn’t worth living if I gain weight.”
B. Hypokalemia
D. Slightly elevated body weight
Implement one-to-one observation during meal times.
B. Anxiety disorder
C. Female gender
Discuss alternative coping strategies with the client
I needed to make my son sick so that someone else would take care of him for a while
Report confusion as a potential indication of toxicity
Identify the client’s level of orientation
I will need to discontinue this medication slowly.
B. Hallucinations
D. Diaphoresis
E. Agitation
I may feel drowsy for a few weeks after starting this medication.”
A. Elevated blood glucose level
D. Headache
The client had a motor vehicle crash last year and sustained a head injury.
A. Void just before taking the medication
C. Wear sunglasses when outside
E. Chew sugarless gum
This medication increase the release of serotonin and norepinephrine”
Regular aspirin would be better choice than ibuprofen.”
Administer the next dose of lithium carbonate as scheduled.
My mother is currently on furosemide for her congestive heart failure.”
C. Apripiprazole
D. Clozapine
E. Asenapine
A. Auditory hallucinations
C. Delusions of grandeur
D. Severe agitation
C. Involuntary arm movements
E. Continual pacing
C. I will be careful not to gain too much weight while taking this medication
A. Seizures
C.Photophobia
D. Dry mouth
E. Irregular pulse
Remove the patch each day after 9 hr
This medication will help prevent seizures during alcohol withdrawal.”
C. Disulfiram
D. Naltrexone
E. Acamprosate
I can expect some diarrhea from taking this medicine”.
Methadone is a replacement for physical dependence to opioids.”
Avoid eating 15 min prior to chewing the gum”
C. Shock and disbelief
A. Developing awareness
B. Restitution
E. Resolution of the loss
D. Recovery
B. Denial
C. Bargaining
D. Anger
E. Depression
A. Interpersonal relationships
B. Culture
D. Religious beliefs
E. Prior experience with loss
You sound angry. Anger is a normal feeling associated with loss.”
B. Substance use
D. Irritability
E. Aggressiveness
A. Bullying of others
B. Threats of suicide
C. Law-breaking activities
Because of this disorder, your child is at increased risk for injury.”
Lethality of the method and availability of means
Ensure that the client swallows medication
A no-suicide contract decreases the client’s risk for a suicide attempt
Request that other staff members remain close by
B. Defensive responses to questions
D. Rapid breathing
E. Facial grimacing
F. Agitation
Move the client away from others
Stop screaming, and walk with me outside.”
Pregnancy increases the risk for violence toward the intimate partner.”
B. Respiratory distress
C. Retinal hemorrhage
D. Altered LOC
E. Increase in head circumference
B. Round burn marks on forearms
E. Areas of ecchymosis on torso
Intentionally causing an older adult to fall is an example of physical violence.
Advise the client about the location of women’s shelters
D. Emotional outburst
E. Difficulty making decisions
I will administer prophylactic treatment for sexually transmitted infections.”
You believe this wouldn’t have happened if you hadn’t been out alone?”
Acquaintance rape often involves alcohol.”
The client is able to open their eyes and respond but is drowsy and falls asleep readily. What is the level of consciousness?
Lethargic
The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. They might not be able to respond verbally. What is the level of consciousness?
Stuporous
The client is unconscious and does not respond to painful stimuli. What is the level of consciousness?
Comatose
How to test a client’s immediate memory
Ask the client to repeat a series of numbers or a list of objects
How to test a client’s recent memory
Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission
How to test a client’s remote memory
Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother’s maiden name
How to assess a client’s ability to calculate
Ask the client to count backward from 100 in sevens
How to assess a client’s ability to think abstractly
Ask the client to interpret something complex such as, “A bird in the hand is worth two in the bush.”
Glasgow coma scale
Used to obtain a baseline assessment of a client’s level of consciousness; highest score is 15 and indicates that the client is awake and responding appropriately; a score of 7 or less indicates that the client is in a coma
Serious mental illness
Includes disorders classified as severe and persistent mental illnesses; clients often have difficulty with ADLs; can be chronic or recurrent
A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply)
A. “To assess cognitive ability, I should ask the client to count backward by sevens.”
B. “To assess affect, I should observe the client’s facial expression.”
C. “To assess language ability, I should instruct the client to write a sentence.”
D. “To assess remote memory, I should have the client repeat a list of objects.”
E. “To assess the client’s abstract thinking, I should ask the client to identify our most recent presidents.”
A. Counting backward by sevens is an appropriate technique to assess a client’s cognitive ability.
B. Observing a client’s facial expression is appropriate when assessing affect.
C. Writing a sentence is an indication of language ability. Remote language is tested by asking the client to state a fact from his past that his verifiable (date of birth). Abstract thinking is tested by asking the client to interpret something.
A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications.
D. Monitoring for adverse effects of medications is an example of a psychobiological intervention. Systematic desensitization is cognitive and behavioral. Teaching coping mechanisms is a counseling or health teaching. Assessing for comorbid conditions is health promotion and maintenance.
A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the client’s perception of her mental health status.
C. Include the client’s family in the interview.
D. Teach the client about her current mental health disorder.
B. Assessment is the priority action. Identifying the client’s perception of her mental health status provides important information about the client’s psychosocial history.
A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place.
A. A client who is stuporous requires vigorous or painful stimuli to elicit a response. B & C occur with comatose patients.
A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion? (Select all that apply)
A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders.
D. The DSM-5 assists nurses in planning care for client’s who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
B, D, & E.
The DSM-5 establishes diagnostic criteria, assists nurses in planning care, and identifies expected findings for mental health disorders. The DSM-5 does not contain client education handouts or recommended pharmacological treatment.
Beneficence
The quality of doing good, can be described as charity
Autonomy
The client’s right to make their own decisions
Justice
Fair and equal treatment for all
Fidelity
Loyalty and faithfulness to the client and to one’s duty
Veracity
Honesty when dealing with a client
Requirements for restraining a patient
Provider must prescribe the restraint in writing; time limits are based on age, 4 hr for adults, 2 hr for ages 9-17, 1 hr for age 8 and younger; must be reviewed every 24 hr; documentation must be done every 15-30 min
False imprisonment
Confining a client to a specific area if the reason for such confinement is for the convenience of the staff
Assault
Making a threat to a client’s person
Battery
Touching a client in a harmful or offensive way
A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod
D. A client who has bipolar disorder and paces quickly around the room while talking to himself
C. A client who is a current danger to self or others is a candidate for a temporary emergency admission.
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse’s actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery
B. Secluding a client for the convenience of the staff is false imprisonment.
A client tells a nurse, “Don’t tell anyone but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me.” Which of the following actions should the nurse take?
A. Keep the client’s communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife.
B. Keep the client’s communication confidential, but watch the client and his roommate closely.
C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of the intention to do so.
C. The information presented by the client is a serious safety issue that the nurse must report to the health care team, using the ethical principle of veracity.
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply)
A. “Client ate most of his breakfast.”
B. “Client was offered 8 oz of water every hr.”
C. “Client shouted obscenities at assistive personnel.”
D. “Client received chlorpromazine 15 mg by mouth at 1000.”
E. “Client acted out after lunch.”
B, C, & D.
Documentation must include how much water was offered and how often, a description of the client’s verbal communication, and the dosage and time of medication administration. Intake and behavior should be documented in the client’s medical record.
A nurse hears a newly licensed nurse discussing a client’s hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?
A. Notify the nurse manager.
B. Tell the nurse to stop discussing the behavior.
C. Provide an in-service program about confidentiality.
D. Complete an incident report.
B. The greatest risk to this client is invasion of privacy through the sharing of confidential information in a public place. The first action the nurse should take is to tell the newly licensed nurse to stop discussing the client’s hallucinations in a public location.
A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son’s condition, which of the following responses should the nurse make?
A. “I think your son is getting better. What have you noticed.”
B. “I’m sure everything will be okay. It just takes time to heal.”
C. “I’m not sure whats wrong. Have you asked the doctor about your concerns?”
D. “I understand you’re concerned. Let’s discuss what concerns you specifically.”
D. This reflects upon and accepts the parents’ feelings and allows them to clarify what they are feeling.
A interjects the nurse’s opinion. B provides false reassurance. C avoids addressing the parent’s concerns directly and indicates disinterest.
Altruism
Dealing with anxiety by reaching out to others
Sublimation
Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression
Suppression
Voluntarily denying unpleasant thoughts and feelings
Repression
Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness
Regression
Sudden use of childlike or primitive behaviors that do not correlate with the person’s current developmental level
Displacement
Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation
Reaction formation
Overcompensating or demonstrating the opposite behavior of what is felt
Undoing
Performing an act to make up for prior behavior
Rationalization
Creating reasonable and acceptable explanations for unacceptable behavior
Dissociation
Creating a temporary compartmentalization or lack of connection between the person’s identity, memory, or how they perceive the environment
Denial
Pretending the truth is not reality to manage the anxiety of acknowledging what is real
Compensation
Emphasizing strengths to make up for weaknesses
Identification
Conscious or unconscious assumption of the characteristics of another individual or group
Intellectualization
Separation of emotional and logical facts when analyzing or coping with a situation or event
Conversion
Responding to stress through the unconscious development of physical manifestations not caused by a physical illness
Splitting
Demonstrating an inability to reconcile negative and positive attributes of self or others
Projection
Attributing one’s unacceptable thoughts and feelings onto another who does not have them
Mild anxiety
Occurs in normal experience of everyday living, increases one’s ability to perceive reality, has an identifiable cause
Moderate anxiety
Slightly reduced perception and processing of information occurs and selective inattention can occur, ability to think clearly is hampered but learning and problem solving can still occur, may show increased HR and RR
Severe anxiety
Perceptual field is greatly reduced with distorted perceptions, learning and problem solving do not occur, may cause increased HR and RR
Panic level anxiety
Characterized by markedly disturbed behavior, cannot process what is occurring in the environment and can lose touch with reality, experiences extreme fight and horror
A nurse is caring for a client who smokes and has lung cancer. The client reports, “I’m coughing because I have that cold that everyone has been getting.” The nurse should identify that the client is using which of the following defense mechanisms?
A. Reaction formation
B. Denial
C. Displacement
D. Sublimation
B. This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.
A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client has a respiratory rate 30/min and says, “This is difficult to comprehend. I feel shaky and nervous.” The nurse should identify that the client is experiencing which of the following levels of anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic
B. Moderate anxiety decreases problem-solving and may hamper the client’s ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious.
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.)
A. Reassure the client that everything will be okay.
B. Discuss prior use of coping mechanisms with the client.
C. Ignore the client’s anxiety so that she will not be embarrassed.
D. Demonstrate a calm manner while using simple and clear directions.
E. Gather information from the client using closed-ended questions.
B & D.
Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor. Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others.
Transference
Occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client’s personal life
Countertransference
Occurs when a health care team member displaces characteristics of people in her past onto a client
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make?
A. “I feel very sorry for the loneliness you must be experiencing.”
B. “Suicide is not the appropriate way to cope with loss.”
C. “Losing someone close to you must be very upsetting.”
D. “I know how difficult it is to lose a loved one.”
C. This statement is an empathetic response that attempts to understand the client’s feelings.
A focuses on the nurse’s feelings. B implies judgment. D focuses on the nurse’s experiences.
A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply)
A. The needs of both participants are met.
B. An emotional commitment exists between the participants.
C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.
C, D, & E.
A therapeutic nurse-client relationship is goal-directed, encourages positive behavioral change, and has an established termination date. It should focus on the client only. An emotional commitment is a characteristic of an intimate or social relationship rather than a therapeutic relationship.
A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior?
A. The client asks the nurse whether she will go out to dinner with him.
B. The client accuses the nurses of telling him what to do just like his ex-girlfriend.
C. The client reminds the nurse of a friend who died from a substance overdose.
D. The client becomes angry and threatens to harm himself.
B. When a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex-girlfriend, this indicates transference.
A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care?
A. Discussing ways to use new behaviors
B. Practicing new problem-solving skills
C. Developing goals
D. Establishing boundaries
A. Discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase.
B occurs in the working phase. C & D occur in the orientation phase.
A nurse is orienting a new client to a mental health unit. When explaining the unit’s community meetings, which of the following statements should the nurse make?
A. “You and a group of other clients will meet to discuss your treatment plans.”
B. “Community meetings have a specific agenda that is established by staff.”
C. “You and the other clients will meet with staff to discuss common problems.”
D. “Community meetings are an excellent opportunity to explore your personal mental health issues.”
C. Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit.
Primary prevention
Promotes health and prevents mental health problems from occurring; teaching a community education program on stress reduction techniques
Secondary prevention
Focuses on early detection of mental illness; screening older adults in the community for depression
Tertiary prevention
Focuses on rehabilitation and prevention of further problems in clients who have previous diagnoses; leading a support group for clients who have completed a substance use disorder program
Partial hospitalization programs
Provide intense short term treatment for clients who are well enough to go home every night and who have a responsible person at home to provide support and a safe environment
Assertive community treatment
Includes nontraditional case management and treatment by an inter professional team for clients who have severe mental illness and are noncompliant with traditional treatment; helps to reduce reoccurrences of hospitalizations and provides crisis intervention, assistance with independent living, and information regarding resources for necessary support services
A nurse is caring several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first?
A. A client who recently burned her arm while using a hot iron at home.
C. A client who says he is hearing a voice that tells him he is not worth living anymore.
D. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview.
C. A client who hears a voice telling him he is not worthy is at greatest risk for self-harm, and the nurse should visit this client first.
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention?
A. Educating clients on health promotion techniques to reduce the risk of depression
B. Performing screenings for depression at community health programs
C. Establishing rehabilitation programs to decrease the effects of depression
D. Providing support groups for clients at risk for depression
C. Rehabilitation programs are an example of tertiary prevention, which deals with prevention of further problems in clients already diagnosed with mental illness.
A & D are primary prevention. B is secondary prevention.
A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply)
A. Educational groups
B. Medication dispensing programs
C. Individual counseling programs
D. Detoxification programs
E. Family therapy
A, B, C, & E.
Community mental health facilities provide educational programs, medication dispensing programs, individual counseling programs, and family therapy. Detoxification programs are provided in a partial hospitalization program.
A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client’s wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow-up care?
A. Receiving daily care from a home health aide
B. Having a weekly visit from a nurse case worker
C. Attending a partial hospitalization program
D. Visiting a community mental health center on a daily basis
C. A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present. Daily care provided by a home health aide and weekly visits from a case worker will not provide adequate care and supervision. Visiting a community mental health center daily will not provide consistent supervision.
A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group?
A. A client in an cute care mental health facility who has fallen several times while running down the hallway
B. A client who lives at home and keeps “forgetting” to come in for his monthly antipsychotic injection for schizophrenia
C. A client in a day treatment program who says he is becoming more anxious during group therapy
D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months
B. An ACT group works with clients who are nonadherent with traditional therapy, such as the client in a home setting who keeps “forgetting” his injection.
Free association
Therapeutic tool that is the spontaneous, uncensored verbalization of whatever comes to a client’s mind
Psychodynamic psychotherapy
Focuses on the client’s present state rather than his early life
Interpersonal psychotherapy (IPT)
Assists clients in addressing specific problems
Dialectical behavior therapy
Cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behaviors; focuses on gradual behavior changes and provides acceptance and validation for these clients
Classical psychoanalysis
Therapeutic process of assessing unconscious thoughts and feelings, focuses on past relationships; clients attend many sessions over the course of months to years
Operant conditioning
The client receives positive rewards for positive behavior (positive reinforcement)
A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy?
A. “Even if my anxiety improves, I will need to continue this therapy for 6 weeks.”
B. “The therapist will focus on my past relationships during our sessions.”
C. “Psychoanalysis will help me reduce my anxiety by changing my behaviors.”
D. “This therapy will address my conscious feelings about stressful experiences.”
B. Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder.
A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique?
A. “I will write down my dreams as soon as I wake up.”
B. “I may begin to associate my therapist with important people in my life.”
C. “I can learn to express myself in a nonaggressive manner.”
D. “I should say the first thing that comes to my mind.”
D. Free association is the spontaneous, uncensored vernalization of whatever comes to a client’s mind.
A is dream analysis. B is transference. C is assertiveness training.
A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care? (Select all that apply)
A. Priority restructuring
B. Monitoring thoughts
C. Diaphragmatic breathing
D. Journal keeping
E. Meditation
A, B, & D. Cognitive reframing utilizes priority restructuring, monitoring thoughts, and journal keeping.
Diaphragmatic breathing and meditation are used in behavioral therapy.
A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. Which of the following types of treatment is this method an example?
A. Aversion therapy
B. Flooding
C. Biofeedback
D. Dialectical behavior therapy
A. Aversion therapy pair a maladaptive behavior with unpleasant stimuli to promote a change in behavior.
A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy?
A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior.
B. Advise the client to say “stop” out loud every time he begins to feel an anxiety response related to an elevator.
C. Gradually expose the client to an elevator while practicing relaxation techniques.
D. Stay with the client in an elevator until his anxiety response diminishes.
C. Systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety response.
A is modeling. B is thought stopping. D is flooding.
Group process
Verbal and nonverbal communication that occurs during group sessions, including how the work progresses
Group norm
The way the group behaves during sessions, and, over time, it provides structure for the group
Homogeneous group
A group in which all members share a certain chosen characteristic, such as diagnosis or gender
Orientation phase of a group
Primary focus is defining the purpose and goals of the group
Working phase of a group
Primary focus is promoting problem solving skills to facilitate behavioral changes
Termination phase of a group
Primary focus is marking the end of group sessions
Nuclear families
Include children who reside with married parents
Blended families
Include children who live with one biological or adoptive parent and a nonrelated stepparent who are married
Cohabitating families
Include children who live with one biological parent and nonrelated adult who are cohabitating
Extended families
Include children living with one biological or adoptive parent and a related adult who is not their parent (grandparent, aunt, uncle, etc.)
Other families
Include children living with related or nonrelated adults who are neither biological nor adoptive parents (grandparents, adult siblings, foster parents)
Enmeshed boundaries
Thoughts, roles, and feelings blend so much that individual roles are unclear
Rigid boundaries
Rules and roles are completely inflexible, these families tend to have members that isolate themselves
A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions?
A. Observes group techniques without interfering with the group process
B. Discusses a technique and then directs members to practice the technique
C. Asks for group suggestions of techniques and then support discussion
D. Suggests techniques and asks group members to reflect on their use
C. Democratic leadership supports group interaction and decision making to solve problems.
A is laissez-faire leadership. B & D are autocratic leadership.
A nurse is planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase? (Select all that apply)
A. Encourage the group to work toward goals
B. Define the purpose of the group
C. Discuss termination of the group
D. Identify informal roles of members within the group
E. Establish an expectation of confidentiality within the group
B, C, & E. During the initial phase, the nurse should identify the purpose of the group, discuss termination of the group, and set the tone of confidentiality.
A & D take place during the working phase.
A nurse working on an acute mental health unit forms a group to focus on self-management of medications. At each of meetings, two of the members use the opportunity to discuss their common interest in gambling on sports. This is an example of which of the following concepts?
A. Triangulation
B. Group process
C. Subgroup
D. Hidden agenda
D. A hidden agenda is when some group members have a different goal than the stated group goals.
A nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he’s the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following?
A. Placation
B. Manipulation
C. Blaming
D. Distraction
B. Manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda.
A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role?
A. A member who praises input from other members
B. A member who follows the direction of other members
C. A member who brags about accomplishments
D. A member who evaluates the group’s performance toward a standard
C. An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals.
Expected findings of acute stress (fight or flight)
Apprehension, unhappiness or sorrow, decreased appetite, increased vital signs, increased metabolism and glucose use, depressed immune system
Expected findings of prolonged stress (maladaptive response)
Chronic anxiety or panic attacks, depression, chronic pain, sleep disturbances, weight gain or loss, increased risk for myocardial infarction and stroke, poor diabetes control, hypertension, fatigue, irritability, decreased ability to concentrate, increased risk for infection
Biofeedback
Use of a sensitive mechanical device to assist the client to gain voluntary control of such autonomic functions as heart rate and blood pressure
A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse include in the discussion?
A. Excessive stressors cause the client to experience distress.
B. The body’s initial adaptive response to stress is denial.
C. Absence of stressors results in homeostasis.
D. Negative, rather than positive, stressors produce a biological response.
A. Distress is the result of excessive or damaging stressors, such as anxiety or anger.
A nurse is discussing acute vs prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply)
A. Chronic pain
B. Depressed immune system
C. Increased blood pressure
D. Panic attacks
E. Unhappiness
B, C, & E. Depressed immune system, increased blood pressure, and unhappiness are responses to acute stress. Chronic pain and panic attacks are responses to prolonged stress.
A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?
A. “Cognitive reframing will help me change my irrational thoughts to something positive.”
B. “Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate.”
C. “Biofeedback causes my body to release endorphins so that I feel less stress and anxiety.”
D. “Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety.”
A. Cognitive reframing helps the client look at irrational thoughts in a more realistic light and to restructure those thoughts in a more positive way. B is biofeedback. C is physical exercise. D is priority restructuring.
A client says she is experiencing increased stress because her significant other is “pressuring me and my kids to go live with him. I love him, but I’m not ready to do that.” Which of the following recommendations should the nurse make to promote a change in the client’s situation?
A. Learn to practice mindfulness
B. Use assertiveness techniques
C. Exercise regularly
D. Rely on the support of a close friend
B. Assertive communication allows the client to assert her feelings and then make a change in the situation.
A nurse is caring for a client who states, “I’m so stressed at work because of my coworker. He expects me to finish his work because he’s too lazy!” When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding?
A. “You really should complete your own work. I don’t think it’s right to expect me to complete your responsibilities.”
B. “Why do you expect me to finish your work? You must realize that I have my own responsibilities.”
C. “It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor.”
D. “When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities.”
D. This response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote a change. A can prompt a defensive reaction. B implies criticism. C is aggressive and threatening.
Indications for electroconvulsive therapy (ECT)
Clients with major depressive disorder whose manifestations are not responsive to pharmacological treatment, clients who are suicidal or homicidal and need rapid treatment, clients who are experiencing psychotic manifestations, clients who have schizophrenia with catatonic manifestations, clients who have schizoaffective disorder, clients who are pregnant and have a schizophrenia spectrum disorder, clients who have bipolar disorder with rapid cycling, clients who are unresponsive to treatment with lithium and antipsychotic medications
Medication management during ECT
IM injection of atropine sulfate 30 min prior to decrease secretions that could cause aspiration, short acting anesthetic at the time of the procedure, muscle relaxant (succinylcholine) after the anesthetic to decrease the risk for injury
Transcranial magnetic stimulation (TMS)
Noninvasive therapy that uses magnetic pulsations to stimulate the cerebral cortex of the brain, indicated for clients with major depressive disorder who are not responsive to pharmacological treatment
Vagus nerve stimulation (VNS)
Provides electrical stimulation through the vagus nerve to the brain through a device that is surgically implanted under the skin on the client’s chest; indicated for clients with depression that is resistant to pharmacological treatment and/or ECT
A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?
A. “It is common to treat depression with ECT before trying medications.”
B. “I can have my depression cured if I receive a series of ECT treatments.”
C. “I should receive ECT once a week for 6 weeks.”
D. “I will receive a muscle relaxant to protect me from injury during ECT.”
D. A muscle relaxant, such as succinylcholine, is administered to reduce the risk for injury during induced seizure activity. ECT should be used when meds are ineffective. ECT does not cure depression. ECT treatment is typically 2-3 times a week for a total of 6-12 treatments.
A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “TMS is indicated for clients who have schizophrenia spectrum disorders.”
B. “I will provide postanesthesia care following TMS.”
C. “TMS treatments usually last 5-10 minutes.”
D. “I will schedule the client for daily TMS treatments for the first several weeks.”
D. TMS is commonly prescribed daily for a period of 4-6 weeks. TMS is not indicated for schizophrenic patients. Postanesthesia care is not necessary after TMS. The procedures lasts 30-40 min.
A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply)
A. Hypotension
B. Paralytic ileus
C. Memory loss
D. Nausea
E. Confusion
C, D, & E. Transient short term memory loss, nausea, and confusion are expected findings immediately following ECT. BP usually elevates after ECT. Paralytic ileum is not a finding.
A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion?
A. Borderline personality disorder
B. Acute withdrawal related to a substance use disorder
C. Bipolar disorder with rapid cycling
D. Dysphoric disorder
C. ECT is indicated for the treatment of bipolar disorder with rapid cycling.
A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (Select all that apply)
A. Voice changes
B. Seizure activity
C. Disorientation
D. Dysphagia
E. Neck pain
A, D, & E. Voice changes, dysphagia, and neck pain are potential adverse effects of VNS. Seizure activity and disorientation are associated with ECT.
Generalized anxiety disorder
Client exhibits uncontrollable, excessive worry for at least 6 months; impairment in or more areas of functioning
Body dysmorphic disorder
Client has preoccupation with perceived flaws or defects in physical appearance
Risk factors for anxiety
Female, family history, acute medical condition, medication adverse effects, substance use/withdrawal
Expected findings of a panic attack
Four or more of the following: palpitations, shortness of breath, choking or smothering sensation, chest pain, nausea, feelings of depersonalization, fear of dying or insanity, chills or hot flashes
Manifestations of generalized anxiety disorder
Restlessness, muscle tension, avoidance of stressful activities or events, increased time and effort required to prepare for stressful activities or events, procrastination in decision making, seeks repeated reassurance
Standardized screening tools for anxiety disorders
Hamilton rating scale for anxiety, fear questionnaire (phobias), panic disorder severity scale, yale-brown obsessive compulsive scale, hoarding scale self-report
Medications for anxiety disorders
SSRIs, SNRIs, benzodiazepines, buspirone, beta blockers, antihistamines, anticonvulsants (mood stabilizing)
A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?
A. Narcissistic behavior
B. Fear of rejection from staff
C. Attempt to reduce anxiety
D. Adverse effect of antidepressant medication
C. Clients who have OCD demonstrate repetitive behaviors in an attempt to suppress persistent thoughts or urges that cause anxiety.
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A. Discuss new relaxation techniques
B. Show the client how to change his behavior
C. Distract the client with a television show
D. Stay with the client and remain quiet
D. During a panic attack, the nurse should quietly remain with the client. This promotes safety and reassurance without additional stimuli. During a panic attack, the client is unable to concentrate on learning new information and further stimuli should be avoided.
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Excessive worry for 6 months
B. Impulsive decision making
C. Delayed reflexes
D. Restlessness
E. Need for reassurance
A, D, & E. Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 3 months, restlessness, and the need for repeated reassurance. GAD is characterized by procrastination and muscle tension rather than impulsivity and delayed reflexes.
A nurse is caring for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?
A. Assessing the client’s risk for self harm
B. Instilling hope for positive outcomes
C. Encouraging the client to participate in group therapy sessions
D. Encouraging the client to participate in treatment decisions
A. The greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self-harm or suicide. This should be assessed first.
A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements should the nurse make?
A. “Tell me about how you are feeling right now.”
B. “You should focus on the positive things in your life to decrease your anxiety.”
C. “Why do you believe you are experiencing this anxiety?”
D. “Let’s discuss the medications your provider is prescribing to decrease your anxiety.”
A. Asking an open-ended question is therapeutic and assists the client in identifying anxiety. Offering advice and asking “why” questions are nontherapeutic. Clients experiencing severe anxiety are unable to concentrate or learn.
Acute stress disorder
Exposure to traumatic events causes anxiety, detachment, and other manifestations about the event for at least 3 days but for no more than 1 month following the event (becomes PTSD if it persists longer than 1 month)
Adjustment disorders
A stressor triggers a reaction causing changes in mood and/or dysfunction in performing usual activities, less severe than ASD and PSTD
Depersonalization
The feeling that a person is observing one’s own personality or body from a distance
Derealization
The feeling that outside events are unreal or part of a dream or that objects appear larger or smaller than they should
Dissociative amnesia
Inability to recall personal information regarding stressful events for a period of time
Dissociative fugue
Type of dissociative amnesia in which the client travels to a new area and is unable to remember one’s own identity and at least some of one’s past, can last weeks to months
Dissociative identity disorder
Client displays more than one distinct personality with a stressful event precipitating the change from one personality to another
Expected findings of ASD and PTSD
Flashbacks, nightmares, avoidance of things that bring back memories of the trauma, trying to avoid thinking about the event, anxiety or depressive disorders, anger/irritability, decreased interest in current activities, guilt, negative self-beliefs, cognitive distortions, detachment from others, inability to experience positive emotional experiences, dissociative manifestations, aggression, hypervigilance with heightened startle response, inability to focus, sleep disturbances, destructive behavior (suicidal thoughts)
Medications for ASD and PTSD
Antidepressants to decrease depression and anxiety (fluoxetine, venlafaxine, mirtazapine, amitriptyline), prazosin (decreases manifestations of hypervigilance and insomnia), propranolol (decreases vital signs and manifestations of anxiety, panic, hypervigilance, and insomnia)
Eye movement desensitization and reprocessing (EMDR)
Therapy using rapid eye movements during desensitization techniques in a multi-phase process; contraindicated for clients who have acute suicidal ideation, psychosis, severe dissociative disorders, detached retina or glaucoma, or severe substance use disorder
A nurse working on an acute mental health unit is caring for a client who has PTSD. Which of the following findings should the nurse expect? (Select all that apply)
A. Difficulty concentrating on tasks
B. Obsessive need to talk about the traumatic event
C. Negative self-image
D. Recurring nightmares
E. Diminished reflexes
A, C, & D. Manifestations of PTSD include the inability to concentrate, feeling guilty and having a negative self image, and recurring nightmares. Clients avoid talking about the event and are hypervigilant.
A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply)
A. Avoid thinking about the incident when it is over
B. Take breaks during the incident for food and water
C. Debrief with others following the incident
D. Hold emotions in check in the days following the incident
E. Take advantage of offered counseling
B, C, & E. Taking breaks for food and water, debriefing after the event, and taking advantage of counseling can help prevent development of a trauma-related disorder.
A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect?
A. The client remembers many details about the traumatic incident
B. The client expresses heightened elation about what is happening
C. The client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred.
D. The client expresses a sense of unreality about the traumatic event
D. The client who has ASD often expresses dissociative manifestations regarding the event, which includes a sense of unreality. Clients with ASD are usually unable to remember details about the incident and react with negative emotions and manifestations occur immediately to a few days following the event.
A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?
A. The client explains that her body seems to be floating above the ground
B. The client has the idea that someone is trying to kill her and steal her money
C. The client states that the furniture in the room seems to be small and far away
D. The client cannot recall anything that happened during the past 2 weeks
C. Stating that one’s surroundings are far away or unreal in some way is an example of derealization. A is depersonalization. B is a paranoid delusion. D is amnesia.
A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?
A. Teach the client to recognize how stress brings on a personality change in the client
B. Repeatedly present the client with information about past events
C. Make decisions for the client regarding routine daily activities
D. Work with the client on grounding techniques
D. Grounding techniques are useful for client who have a dissociate disorder and are experiencing manifestations of derealization. A is best for dissociative identity disorder. Flooding should be avoided to decrease anxiety. The nurse should encourage the client to make his own decisions.
Seasonal affective disorder (SAD)
A form of depression that occurs seasonally, usually during the winter, when there is less daylight; best treated with light therapy
Dysthymic disorder
Milder form of depression that usually has an early onset and lasts at least 2 years for adults and 1 year for children; contains at least 3 clinical findings of depression
A nurse working in an acute mental health facility is caring for a 35-year-old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (Select all that apply)
A. Age
B. Gender
C. History of chronic asthma
D. Smoking
E. Being married
A, B, C, & D. Being between the ages of 15-40, being female, having a chronic illness, and substance use are risk factors for depression.
A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse’s priority?
A. Placing the client on one-to-one observation
B. Assisting the client to perform ADLs
C. Encouraging the client to participate in counseling
D. Teaching the client about medication adverse effects
A. The greatest risk for a client who has MDD and comorbid anxiety is injury due to self harm. The highest priority intervention is placing the client on one-to-one observation.
A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?
A. “I can expect my problems with PMDD to be worst when I’m menstruating.”
B. “I will use light therapy 30 min a day to prevent further recurrences of PMDD.”
C. “I am aware that my PMDD causes me to have rapid mood swings.”
D. “I should increase my caloric intake with a nutritional supplement when my PMDD is active.”
C. A clinical finding of PMDD is emotional lability. Clinical findings of PMDD are present during the luteal phase of the menstrual cycle just prior to menses. Light therapy is best for SAD. PMDD increases the risk for weight gain due to overeating so the client should not increase her caloric intake.
A charge nurse is discussing the care of a client who has MDD with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “Care during the continuation phase focuses on treating continued manifestations of MDD.”
B. “The treatment of MDD during the maintenance phase lasts for 6-12 weeks.”
C. “The client is at greatest risk for suicide during the first weeks of an MDD episode.”
D. “Medication and psychotherapy are most effective during the acute phase of MDD.”
C. The client is at greatest risk for suicide during the acute phase of MDD. Care in the continuation phase focuses on relapse prevention. The maintenance phase of treatment can last for a year or more. Med therapy and psychotherapy are used during the continuation phase.
A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect?
A. Wide fluctuations of mood
B. Report of a minimum of 5 clinical findings of depression
C. Presence of manifestations for at least 2 years
D. Inflated sense of self-esteem
C. Manifestations of dysthymic disorder last for at least 2 years in adults. A occurs in bipolar disorder. B occurs with MDD. Dysthymic disorder causes a decreased self-esteem.
Rapid cycling
Four or more episodes of hypomania or acute mania within 1 year
Bipolar I
Bipolar II
Cyclothymic disorder
In BI the client has at least one episode of mania alternating with major depression. In BII the client has one or more hypomanic episodes alternating with major depressive disorders. In cyclothymic disorder the client has at least 2 years of repeated hypomanic manifestations that do not meet the criteria for hypomanic episodes alternating with minor depressive episodes.
Mood Disorders Questionnaire
A standardized tool that places mood progression on a continuum from hypomania (euphoria) to acute mania (extreme irritability and hyperactivity) to delirious mania (completely out of touch with reality)
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)
A. Provide flexible client behavior expectations
B. Offer concise explanations
C. Establish consistent limits
D. Disregard client complaints
E. Use a firm approach with communication
B, C, & E. Offering concise explanations improves the client’s ability to focus. Setting limits decreases the risk for client manipulation. Using a firm approach promotes structure.
A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?
A. “ECT is the recommended initial treatment for bipolar disorder.”
B. “ECT is contraindicated for clients who have suicidal ideation.”
C. “ECT is effective for client’s who are experiencing severe mania.”
D. “ECT is prescribed to prevent relapse of bipolar behavior.”
C. ECT is appropriate for the treatment of severe mania associated with bipolar disorder. Pharmacological intervention is the recommended initial treatment. ECT is effective in suicidal patients. ECT is prescribed for acute episodes of bipolar disorder rather than the prevention of relapse.
A nurse is caring for a client who has bipolar disorder. The client states, “I am very rich, and I feel I must give my money to you.” Which of the following responses should the nurse make?
A. “Why do you think you feel the need to give money away?”
B. “I am here to provide care and cannot accept this from you.”
C. “I can request that your case manager discuss appropriate charity options with you.”
D. “You should know that giving away your money is inappropriate.”
B. This statement is matter of fact and concise and is a therapeutic response. A is a why question. C does not recognize the possibility of poor judgment. D offers disapproval.
A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?
A. Set consistent limits for expected client behavior
B. Administer prescribed medications as scheduled
C. Provide the client with step by step instructions during hygiene activities
D. Monitor the client for escalating behavior
D. Monitoring for escalating behavior addresses the client’s priority need for safety and is therefore the priority nursing action.
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply)
A. Use caffeine in moderation to prevent relapse
B. Difficulty sleeping can indicate a relapse
C. Begin taking your medications as soon as a relapse begins
D. Participating in psychotherapy can help prevent a relapse
E. Anhedonia is a clinical manifestation of a depressive relapse
B, D, & E. Sleep disturbances and anhedonia can indicate a relapse. Psychotherapy is helpful in preventing a relapse. The client should caffeine use and should take prescribed medications to prevent and minimize a relapse.
Schizotypal personality disorder
The client has impairments of personality (self and interpersonal) functioning but is not as severe as schizophrenia
Delusional disorder
The client experiences delusional thinking for at least 1 month but self or interpersonal functioning are not markedly impaired
Brief psychotic disorder
The client has psychotic manifestations that last 1 day to 1 month in duration
Schizophreniform disorder
The client has manifestations similar to schizophrenia but the duration is 1-6 months and social/occupational dysfunction might not be present
Positive symptoms of psychotic disorders
Manifestation of things that are not normally present such as hallucinations, delusions, alterations in speech, and bizarre behavior
Negative symptoms of psychotic disorders
Absence of things that are normally present, more difficult to treat; blunted or flat affect, alogia (poverty of thought or speech), anergia (lack of energy), anhedonia (lack of pleasure or joy), avocation (lack of motivation)
Ideas of reference
Misconstrues trivial events and attaches personal significance to them, such as believing that others are talking about them
Persecution
Feels singled out for harm by others (being hunted down by the FBI)
Grandeur
Believe that they are all powerful and important, like a god
Thought broadcasting
Believe that their thoughts are being heard by others
Flight of ideas/loose association
The client might say sentence after sentence but each sentence can relate to a different topic
Neologisms
Made up words that have meaning only to the client
Echolalia
The clients repeat words spoken to them
Clang association
Meaningless rhyming of words
Word salad
Words jumbled together with little meaning or significance to the listener
A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, “The voices won’t leave me alone!” Which of the following statements should the nurse make? (Select all that apply)
A. “When did you start hearing the voices?”
B. “The voices are not real, or else we would both hear them.”
C. “It must be scary to hear voices.”
D. “Are the voices telling you to hurt yourself?”
E. “Why are the voices talking to only you?”
A, C, & D. The nurse should ask directly about the hallucination, focus on the client’s feelings, and assess for command hallucinations and the client’s risk for injury to self or others.
A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply)
A. Auditory hallucination
B. Lack of motivation
C. Use of clang association
D. Delusion of persecution
E. Constantly waving arms
F. Flat affect
A, C, D, & E. Hallucinations, speech alterations, delusions, and bizarre movements are positive symptoms. Lack of motivation and flat affect are negative symptoms.
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?
A. “I am a superhero and am immortal.”
B. “I am no one, and everyone is me.”
C. “I feel monsters pinching me all over.”
D. “I know that you are stealing my thoughts.”
B. This indicates the client is experiencing loss of identity or depersonalization. A is a delusion of grandeur. C is a tactile hallucination. D is thought withdrawal.
A nurse is caring for a client on an acute mental health unit The client reports hearing voices that are telling her to “kill your doctor.” Which of the following actions should the nurse take first?
A. Use therapeutic communication to discuss the hallucination with the client
B. Initiate one-to-one observation of the client
C. Focus the client on reality
D. Notify the provider of the client’s statement
B. A client who is experiencing a command hallucination is at risk for injury to self or others and should be placed on one-to-one observation.
A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse’s questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take?
A. Stop the interview at this point, and resume later when the client is better able to concentrate.
B. Ask the client, “Are you seeing something on the ceiling?”
C. Tell the client, “You seem to be looking at something on the ceiling. I see something there, too.”
D. Continue the interview without comment on the client’s behavior.
B. The nurse should ask the client directly about the hallucination to identify client needs and assess for a potential risk for injury.
Characteristics of personality disorders
Inflexibility/maladaptive responses to stress, compulsiveness and lack of of social restraint, inability to emotionally connect in social and professional relationships, tendency to provoke interpersonal conflict, ability to merge personal boundaries with others
Cluster A personality disorders (odd or eccentric traits)
Paranoid (distrust and suspiciousness), schizoid (emotional detachment, disinterest in close relationships, indifference to praise or criticism), and schizotypal (interpersonal difficulties, eccentric appearance, magical thinking)
Cluster B personality disorders (dramatic, emotional, or erratic traits)
Antisocial (disregard for others), borderline (instability of affect, identity, and relationships as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment), histrionic (emotional attention-seeking behavior), and narcissistic (arrogance, grandiose views of self-importance, the need for consistent admiration, and lack of empathy)
Cluster C personality disorders (anxious or fearful traits, insecurity and inadequacy)
Avoidant (social inhibition and avoidance of all situations that require interpersonal contact), dependent (extreme dependency in a close relationship), and obsessive-compulsive (perfectionism with a focus on orderliness and control)
Medications for personality disorders
Antidepressants, anxiolytics, antipsychotics, and mood stabilizers
A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “I can promote my client’s sense of control by establishing a schedule.”
B. “I should encourage clients who have a schizoid personality disorder to increase socialization.”
C. “I should practice limit-setting to help prevent client manipulation.”
D. “I should implement assertiveness training with clients who have antisocial personality disorder.”
C. When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation. The nurse should ask for the client’s input instead of making a schedule, avoid trying to increase socialization for a client who has schizoid, and implement assertiveness training for clients who have dependent and histrionic personality disorders.
A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?
A. “I’m scared that you’re going to leave me.”
B. “I’ll go to group therapy if you’ll let me smoke.”
C. “I need to feel that everyone admires me.”
D. “I sometimes feel better if I cut myself.”
A. Clients who have avoidant personality disorder often have fear of abandonment. This type of statement is expected. B occurs in antisocial personality disorder. C occurs in narcissistic personality disorder. D occurs in borderline personality disorder.
A nurse is caring for a client who has borderline personality disorder. The client says, “The nurse on the evening shift is always nice! You are the meanest nurse ever!” The nurse should recognize the client’s statement as an example of which of the following defense mechanisms?
A. Regression
B. Splitting
C. Undoing
D. Identification
B. Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has BPD tends to see a person as all bad one time and all good another time.
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Demonstrates extreme anxiety when placed in a social situation
B. Has difficulty making even simple decisions
C. Attempts to convince other clients to give him their belongings
D. Becomes agitated if his personal area is not neat and orderly
E. Blames others for his past and current problems
C & E. Exploitation/manipulation and failure to accept personal responsibility are findings of antisocial personality disorder. A occurs in avoidant personality disorder. B occurs in narcissistic personality disorder. D occurs in OCD.
A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (Select all that apply)
A. Difficulty in getting along with other members of a group
B. Belief in the ability to become invisible during times of stress
C. Display of defense mechanisms when routines are changed
D. Claiming to be more important than other persons
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
A, C, & E. Difficulty with social and professional relationships, maladaptive response to stress, difficulty understanding personal boundaries are characteristics seen in all personality disorders. B & D do not occur in all personality disorders.
Confabulation
The client can make up stories when questioned about events or activities that she does not remember; this can seem like lying, but it is actually an unconscious attempt to save self-esteem and prevent admitting that she does not remember the occasion
Delirium
Rapid over a short period of time (hours or days), emergency; impairments in memory, judgment, ability to focus, and ability to calculate (can fluctuate at night); altered LOC, rapid personality changes, labile mood, unstable vital signs; cause unknown
Neurocognitive disorder
Gradual deterioration over months or years; impairments in memory, judgment, speech (aphasia), ability to recognize familiar objects (agnosia), executive functioning, and movement (apraxia), do not change throughout the day; LOC unchanged, personality change is gradual, vital signs are stable; irreversible
Cholinesterase inhibitors
Donepezil, rivastigmine, galantamine; slow cognitive deterioration of alzheimer’s; contraindicated in patients who have asthma or other obstructive pulmonary disorders; start low dose and gradually increase; give once daily at bedtime
Cholinesterase side effects
Nausea, vomiting, diarrhea, bradycardia, syncope
Cholinesterase interactions
NSAIDs cause GI bleeding; antihistamines, TCAs, and conventional antipsychotics reduce effectiveness
. A nurse is caring for a client who has early stage Alzheimer’s disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication?
A. “You should avoid taking over-the-counter acetaminophen while on donepezil.”
B. “You can expect the progression of cognitive decline to slow with donepezil.”
C. “You will be screened for underlying kidney disease prior to starting donepezil.”
D. “You should stop taking donepezil if you experience nausea or diarrhea.”
B. Donepezil slows the cognitive deterioration of Alzheimer’s disease. Clients should avoid NSAIDs, not acetaminophen. Clients should be screened for heart and pulmonary disease. The client should not abruptly stop the medication.
A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, “I have to get home.” Which of the following statements should the nurse make?
A. “You have forgotten that this is your home.”
B. “You cannot go outside without a staff member.”
C. “Why would you want to leave? Aren’t you happy with your care?”
D. “I am your nurse. Let’s walk together to your room.”
D. It is appropriate for the nurse to introduce herself with each new interaction and to promote reality in a calm, reassuring manner. A is argumentative. B is a negative statement. C is a why question.
A home health nurse is making a visit to a client who has Alzheimer’s disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client’s risk for injury? (Select all that apply)
A. Install childproof door locks.
B. Place rugs over electrical cords.
C. Mark cleaning supplies with colored tape.
D. Place the client’s mattress on the floor.
E. Install light fixtures above stairs.
A, D, & E. Door locks that are difficult to open reduce the risk of the client wandering. Placing the client’s mattress on the floor and installing lights above stairs reduce the risk for falls. Rugs are a fall hazard. Cleaning supplies should be in locked cupboards.
A nurse is making a home visit to a client who is in the late stage of Alzheimer’s disease. The client’s partner, who is the primary caregiver, wishes to discuss concerns about the client’s nutrition and the stress of providing care. Which of the following actions should the nurse take?
A. Verify that a current power of attorney document is on file.
B. Instruct the client’s partner to offer finger foods to increase oral intake.
C. Provide information on resources for respite care.
D. Schedules the client for placement of an enteral feeding tube.
C. Providing information on resources for respite care is an appropriate action to provide the client’s partner with a break from caregiver responsibilities.
A nurse is performing an admission assessment for a client who has delirium related to an acute UTI. Which of the following findings should the nurse expect? (Select all that apply)
A. History of gradual memory loss
B. Family report of personality changes
C. Hallucinations
D. Unaltered level of consciousness
E. Restlessness
B, C, & E. The client who has delirium can experience rapid personality changes, perceptual disturbances, and restlessness. Delirium is rapid and LOC is altered.
Effects of alcohol intoxication
Excess: slurred speech, nystagmus, memory impairment, altered judgment, decreased motor skills, decreased LOC, respiratory arrest, peripheral collapse, and death Chronic: direct cardiovascular damage, liver damage, erosive gastritis and GI bleeding, acute pancreatitis, sexual dysfunction
Alcohol withdrawal manifestations
Abdominal cramping, vomiting, tremors, restlessness, inability to sleep, increased HR/RR/BP/temp, transient hallucinations or illusions, anxiety, and tonic clonic seizures
Effects of benzodiazepine intoxication
Increased drowsiness and sedation, agitation, slurred speech, uncoordinated motor activity, nystagmus, disorientation, nausea/vomiting, respiratory depression, decreased LOC
Benzodiazepine withdrawal manifestations
Anxiety, insomnia, diaphoresis, hypertension, possible psychotic reactions, hand tremors, nausea, vomiting, hallucinations or illusions, psychomotor agitation, and possible seizure activity
Effects of cannabis intoxication
Lung cancer, chronic bronchitis, occurrence of paranoia, increased appetite, dry mouth, tachycardia
Cannabis withdrawal manifestations
Irritability, aggression, anxiety, insomnia, lack of appetite, restlessness, depressed mood, abdominal pain, tremors, diaphoresis, fever, headache
Effects of cocaine intoxication
Dizziness, irritability, tremor, blurred vision, hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, possible cardiovascular collapse and death
Cocaine withdrawal manifestations
Depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation
Effects of amphetamine intoxication
Impaired judgment, psychomotor agitation, hypervigilance, extreme irritability, tachycardia, elevated BP
Amphetamine withdrawal manifestations
Craving, depression, fatigue, sleeping
Effects of nicotine intoxication
Hypertension, stroke, respiratory disease, irritation to oral mucous membranes, cancer
Nicotine withdrawal manifestations
Abstinence syndrome evidenced by irritability, craving, nervousness, restlessness, anxiety, insomnia, increased appetite, difficulty concentrating, anger, and depressed mood
Effects of opioid intoxication
Slurred speech, impaired memory, pupillary changes, decreased respirations and LOC, and maladaptive behavioral or psychological changes (impaired judgment or social functioning)
Opioid withdrawal manifestations
Abstinence syndrome which begins with sweating and rhinorrhea progressing to piloerection, tremors, and irritability followed by severe weakness, diarrhea, fever, insomnia, pupil dilation, nausea, vomiting, pain in the muscles and bones, and muscle spasms
Effects of inhalant intoxication
Behavioral or psychological changes, dizziness, nystagmus, uncoordinated movements or gait, slurred speech, drowsiness, hyporeflexia, muscle weakness, diplopia, stupor or coma, respiratory depression, and possible death; no withdrawal manifestations
Effects of hallucinogen intoxication
Anxiety, depression, paranoia, impaired judgment, impaired social functioning, pupil dilation, tachycardia, diaphoresis, palpitations, blurred vision, tremors, incoordination, and panic attacks
Hallucinogen withdrawal manifestations
Hallucinogen persisting perception disorder: visual disturbances or flashback hallucinations can occur intermittently for years
Effects of caffeine intoxication
Commonly occurs with ingestion of greater 250 mg (one 2 oz high energy drink can contain 215-240 mg caffeine); tachycardia and arrhythmias, flushed face, muscle twitching, restlessness, diuresis, GI disturbances, anxiety, insomnia
Caffeine withdrawal manifestations
Can occur within 24 hr of last consumption; headache, nausea, vomiting, muscle pain, irritability, inability to focus, drowsiness
A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation?
A. Older adults require higher doses of a substance to achieve a desired effect.
B. Older adults commonly use rationalization to cope with a substance use disorder.
C. Older adults are at an increased risk for substance use following retirement.
D. Older adults develop substance use to mask manifestations of dementia.
C. Retirement and other life change stressors increase the risk for substance use in older adults.
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply)
A. Bradycardia
B. Fine tremors of both hands
C. Hypotension
D. Vomiting
E. Restlessness
B, D, & E. Fine tremors of both hands, vomiting, and restlessness are expected findings of alcohol withdrawal. Alcohol withdrawal would cause tachycardia rather than bradycardia and hypertension rather than hypotension.
A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority?
A. Orient the client frequently to time, place, and person.
B. Offer fluids and nourishing diet as tolerated.
C. Implement seizure precautions.
D. Encourage participation in group therapy sessions.
C. The greatest risk to the client is injury. Implementing seizure precautions is the priority intervention.
A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol?
A. Chlordiazepoxide
B. Bupropion
C. Disulfiram
D. Carbamazepine
C. The nurse should expect the administer disulfiram to help the client maintain abstinence from alcohol. A & D are for alcohol withdrawal. B is for nicotine withdrawal.
A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicate an understanding of the teaching? (Select all that apply)
A. “We need to understand that she is responsible for her disorder.”
B. “Eliminating any codependent behavior will promote her recovery.”
C. “She should participate in an Al-Anon group to help her recover.”
D. “The primary goal of her treatment is abstinence from substance use.”
E. “She needs to discuss her feelings about substance use to help her recover.”
B, D, & E. Families should be aware of codependent behavior, such as enabling, that can promote substance use rather than recovery. Abstinence is the primary treatment goal for a client who has a substance use disorder. Clients must acknowledge their feelings about substance use as part of a substance use recovery program. Clients are responsible for their recovery not their disease. Al-Anon is for family members.
A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (Select all that apply)
A. “What is your relationship like with your family.”
B. “Why do you want to lose weight?”
C. “Would you describe your current eating habits?”
D. “At what weight do you believe you will look better?”
E. “Can you discuss your feelings about your appearance?”
A, C, & E. An anorexia assessment should include family and interpersonal relationships, current eating habits, and the client’s perception of the issue. B is a “why” question and D promotes cognitive distortion.
A nurse is caring for an adolescent client who has anorexia nervosa with rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion catastrophizing?
A. “Life isn’t worth living if I gain weight.”
B. “Don’t pretend like you don’t know how fat I am.”
C. “If I could be skinny, I know I’d be popular.”
D. “When I look in the mirror, I see myself as obese.”
A. This reflects catastrophizing because the client’s perception of her appearance or situation is much worse than her current condition. B is personalization. C is overgeneralization.
A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply)
A. Amenorrhea
B. Hypokalemia
C. Mottling of the skin
D. Slightly elevated body weight
E. Presence of lanugo on the face
B & D. Hypokalemia and a normal weight or slightly elevated weight are findings of bulimia. Amenorrhea, skin mottling, and lanugo are expected findings of anorexia.
A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions should the nurse include in the client’s plan of care?
A. Allow the client to select preferred meal times.
B. Establish consequences for purging behavior.
C. Provide the client with a high-fat diet at the start of treatment.
D. Implement one-to-one observation during meal times.
D. The nurse should closely monitor the client during and after meals to prevent purging. The nurse should provide structured milieu including meal times, a positive approach to client care, and should limit high-fat foods.
A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following responses should the nurse make?
A. “Many clients are concerned about their weight. However the dietitian will ensure that you don’t get too many calories in your diet.”
B. “Instead of worrying about your weight, try to focus on other problems at this time.”
C. “I understand you have concerns about your weight, but first, let’s talk about your recent accomplishments.”
D. “You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you.”
C. This acknowledges the client’s concern and then focuses the conversation on the client’s accomplishments, which can promote client self-esteem and self-image. A, B, & D minimize and generalize the client’s concern.
Illness anxiety disorder
Misinterprets physical manifestations as evidence of a serious disease process
Conversion disorder
Client exhibits neurologic manifestations in the absence of a neurologic diagnosis
Factitious disorder
The conscious decision by the client to report physical or psychological manifestations for atttention
A nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply)
A. Age older than 65 years
B. Anxiety disorder
C. Female gender
D. Coronary artery disease
E. Obesity
B & C. Anxiety disorder and female gender are risk factors for somatic symptom disorder. Age 16-25 years is a risk factor for somatic symptom disorder. Coronary artery disease and obesity are risk factors for somatic symptom disorders.
A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client as risk for conversion disorder?
A. Death of a child 2 months ago
B. Recent weight loss of 30 lb
C. Retirement 1 year ago
D. History of migraine headaches
A. The death of a child 2 months ago is an acute stressor that places the client at risk for conversion disorder.
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Obsessive thoughts about disease
B. History of childhood abuse
C. Avoidance of health care providers
D. Depressive disorder
E. Narcissistic personality
A, B, C, & D. Obsessive thoughts about disease, a history of child abuse, avoidance of health care providers, and a depressive disorder are expected findings in a client who has illness anxiety disorder. Low self-esteem, rather than narcissism, is an expected finding in a client who has illness anxiety disorder.
A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include?
A. Encourage the client to spend time alone in his room
B. Monitor the client for self-harm once per day
C. Allow the client unlimited time to discuss physical manifestations
D. Discuss alternative coping strategies with the client
D. The nurse should discuss alternative coping strategies with the client. The nurse should encourage communication with others, continuously monitor the client for risk of self-harm, and should set a time limit for discussion of physical manifestations.
A nurse is counseling a client who has factitious disorder imposed on another. Which of the following client statements should the nurse expect?
A. “I had to pretend I was injured in order to get disability benefits.”
B. “I know that my abdominal pain is caused by a malignant tumor.”
C. “I needed to make my son sick so that someone else would take care of him for a while.”
D. “I became deaf when I heard that my husband was having an affair with my best friend.”
C. A client who has factitious disorder imposed on another often consciously injures another person or causes them to be sick due to a personal need for attention or relief of responsibility. A is malingering. B is found in illness anxiety disorder. D is found in conversion disorder.
Benzodiazepines
Alprazolam, diazepam, lorazepam, chlordiazepoxide, clorazepate, oxazepam, clonazepam; used to treat anxiety disorders, seizure disorders, insomnia, muscle spasm, alcohol withdrawal (prevention and treatment of acute manifestations), induction of anesthesia, and amnesic prior to surgery or procedures
Side effects of benzodiazepines
CNS depression (sedation, lightheadedness, ataxia, decreased cognitive function), anterograde amnesia, paradoxical response (insomnia, excitation, euphoria, anxiety, rage)
Atypical anxiolytic/nonbarbiturate anxiolytics
Buspirone; less potential for dependency than other antianxiety meds, does not result in sedation or potentiate effects of other CNS depressants; initial responses take 1 week and at least 2-6 weeks to reach full effects; should not be used with MAOIs or grapefruit juice
Side effects of buspirone
Dizziness, nausea, headache, lightheadedness, agitation
Selective serotonin reuptake inhibitors (SSRIs)
Paroxetine, sertraline, citalopram, escitalopram, fluoxetine, fluvoxamine; may take up to 4 weeks to produce therapeutic medication levels; used to treat depression, anxiety disorders, and trauma/stressor related disorders; should not be used with MAOIs or TCAs
Side effects of SSRIs
Early adverse effects: nausea, diaphoresis, tremor, fatigue, drowsiness Later adverse effects: sexual dysfunction, weight gain, headache GI bleeding, weight changes, hyponatremia, serotonin syndrome (agitation confusion, disorientation, difficulty concentrating, anxiety, hallucinations, hyperreflexia, fever, diaphoresis, incoordination, tremors), bruxism (teeth grinding), withdrawal syndrome (nausea, sensory disturbances, anxiety, tremor, malaise, unease)
Serotonin norepinephrine reuptake inhibitors (SNRIs)
Venlafaxine, duloxetine, desvenlafaxine; used for major depression, panic disorders, and generalized anxiety disorder; should not be used with MAOIs, alcohol, opioids, antihistamines, or sedatives/hypnotics
Side effects of SNRIs
Headache, nausea, agitation, anxiety, dry mouth, sleep disturbances, hyponatremia, anorexia/weight loss, hypertension, sexual dysfunction
A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following information should the nurse provide?
A. Three to six weeks of treatment is required to achieve therapeutic benefit
B. Combining alcohol with diazepam will produce a paradoxical response
C. Diazepam has a lower risk for dependence than other antianxiety medications
D. Report confusion as a potential indication of toxicity
D. Confusion is a potential indication of diazepam toxicity that the client should report. Buspirone, rather than diazepam, requires 3-6 weeks to achieve therapeutic benefit. Combining alcohol with diazepam would cause CNS and respiratory depression. Diazepam is highly addictive and should be used short term.
A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse’s priority?
A. Administer flumazenil
B. Identify the client’s level of orientation
C. Infuse IV fluids
D. Prepare the client for gastric lavage
B. When taking the nursing process approach to client care, the initial step is assessment.
A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication?
A. “I will take the medication at bedtime.”
B. “I will follow a low-sodium diet while taking this medication.”
C. “I will need to discontinue this medication slowly.”
D. “I will be at risk for weight loss with long term use of this medication.”
C. When discontinuing fluoxetine, the client should taper the medication slowly to reduce the risk of withdrawal syndrome. Fluoxetine should be taken in the morning to minimize sleep disturbances. The client is at risk for hyponatremia and weight gain while taking fluoxetine.
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply)
A. Hypothermia
B. Hallucinations
C. Muscular flaccidity
D. Diaphoresis
E. Agitation
B, D, & E. Hallucinations, diaphoresis, and agitation are indications of serotonin syndrome. Fever and muscle tremors are indications of serotonin syndrome.
A nurse is caring for a client who takes paroxetine to treat PTSD. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client’s bruxism? (Select all that apply)
A. Concurrent administration of buspirone
B. Administration of a different SSRI
C. Use of a mouth guard
D. Changing to a different class of antianxiety medication
E. Increasing the dose of paroxetine
A, C, & D. Concurrent administration of buspirone, using a mouth guard, and changing to a different class are effective measures. Other SSRIs will have the same effect. Increasing the dose will worsen the bruxism.
Tricyclic antidepressants (TCAs)
Amitriptyline, imipramine, doxepin, nortriptyline, amoxapine, trimipramine; used to treat depressive disorders, neuropathic pain, fibromyalgia, anxiety disorders, insomnia, and bipolar disorder; should not be used in clients who have seizure disorders; should not be used with MAOIs and antihistamines
Side effects of TCAs
Orthostatic hypotension, anticholinergic effects (dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia), sedation, toxicity (dysrhythmias, mental confusion, agitation, seizures, coma), decreased seizure threshold, excessive sweating, increased appetite
Monoamine oxidase inhibitors (MAOIs)
Phenelzine, isocarboxazide, tranylcypromine, selegiline; used to treat depression, bulimia, and atypical depression; should not be taken with SSRIs, TCAs, or OTC meds; avoid caffeine and tyramine (aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein, some dietary supplements, some beers, and red wine)
Side effects of MAOIs
CNS stimulation (anxiety, agitation, hypomania, mania), orthostatic hypotension, hypertensive crisis, rash
Atypical antidepressants
Bupropion, inhibits dopamine uptake; used to treat depression, alternative to SSRIs for those unable to tolerate the sexual dysfunction side effects, an aid to quit smoking, and prevent of SAD; should not be used with MAOIs or SSRIs; contraindicated in patients with anorexia or bulimia
Side effects of bupropion
Headache, dry mouth, GI distress, constipation, increased HR, nausea, restlessness, insomnia, appetite suppression leading to weight loss, seizures at high doses
Mirtazapine
Atypical antidepressant, increases the release of serotonin and norepinephrine; therapeutic effects occur sooner with less sexual dysfunction than SSRIs; well tolerated but adverse effects include sleepiness, increased appetite and weight gain, and elevated cholesterol
Trazodone
Atypical antidepressant, moderate selective blockade of serotonin receptors; sedation may be an issue so it can be indicated in a client who has insomnia caused by an SSRI; may cause priapism
A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
A. “While taking this medication, I’ll need to stay out of the sun to avoid a skin rash.”
B. “I may feel drowsy for a few weeks after starting this medication.”
C. “I cannot eat my favorite pizza with pepperoni while taking this medication.”
D. “This medication will help me lose the weight that I have gained over the last year.”
B. Sedation is an adverse effect of amitriptyline during the first few weeks of therapy. Skin rash is associated with SSRIs. Foods such as pepperoni should be avoided if the client is taking an MAOI. TCAs cause weight gain not weight loss.
A nurse is caring for a client who is taking phenelzine. For which of the following adverse effects should the nurse monitor? (Select all that apply)
A. Elevated blood glucose level
B. Orthostatic hypotension
C. Priapism
D. Headache
E. Bruxism
B & D. Orthostatic hypotension and headache are adverse effects of phenelzine. Priapism is an adverse effect of trazodone. Bruxism is an adverse effect of SSRIs.
A nurse is review the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider?
A. The client has a family history of SAD.
B. The client currently smokes 1.5 packs of cigarettes per day.
C. The client had a motor vehicle crash last year and sustained a head injury.
D. The client has a BMI of 25 and has gained 10 lb over the last year.
C. The greatest risk to the client is development of seizures. Bupropion can lower the seizure threshold and should be avoided by clients who have a history of a head injury. This is the highest priority.
A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (Select all that apply)
A. Void just before taking the medication
B. Increase the dietary intake of potassium
C. Wear sunglasses when outside
D. Change positions slowly when getting up
E. Chew sugarless gum
A, C, & E. Voiding just before taking the med will minimize urinary hesitancy and retention. Wearing sunglasses when outside will minimize photophobia. Chewing sugarless gum will minimize dry mouth.
A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?
A. “This medication increases the release of serotonin and norepinephrine.”
B. “I will need to monitor the client for hyponatremia while taking this medication.”
C. “This medication is contraindicated for clients who have an eating disorder.”
D. “Sexual dysfunction is a common adverse effect of this medication.”
A. Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine. Hyponatremia is an adverse effect of venlafaxine. Bupropion is contraindicated for clients who have an eating disorder. Sexual dysfunction is an adverse effect of SSRIs.
Lithium carbonate
Mood stabilizer, produces neurochemical changes in the brain including serotonin receptor blockade, decreases atrophy and/or increases neuronal growth; used in the treatment of bipolar disorders to control episodes of acute mania, help prevent the return of mania or depression, and decrease the incidence of suicide
Side effects of lithium
Nausea, diarrhea, abdominal pain, fine hand tremors, polyuria, mild thirst, weight gain, renal toxicity, goiter and hypothyroidism, bradydysrhythmias, hypotension, electrolyte imbalances, and toxicity
Early lithium toxicity
Less than 1.5 mEq/L; manifestations: diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremors, slurred speech, lethargy
Advanced lithium toxicity
1.5-2.0 mEq/L; manifestations: mental confusion, sedation, poor, coordination, coarse tremors, ongoing GI distress (nausea, vomiting, diarrhea)
Severe lithium toxicity
2.0-2.5 mEq/L; manifestations: extreme polyuria of dilute urine, tinnitus, giddiness, jerking movements, blurred vision, ataxia, seizures, severe hypotension and stupor leading to coma, possible death from respiratory complications; greater than 2.5 mEq/L can lead to coma and death
Lithium interactions
Diuretics and NSAIDs can lead to toxicity; anticholinergics can cause abdominal discomfort due to urinary retention and polyuria
Mood-stabilizing antiepileptic drugs
Carbamazepine, valproate, lamotrigine; help treat and manage bipolar disorder and prevent relapse of manic and depressive episodes, particularly useful for clients who have mixed mania and rapid cycling bipolar disorders
Side effects of antiepileptic drugs
Carbamazepine: nystagmus, double vision, vertigo, staggering gait, headache, leukopenia, anemia, thrombocytopenia, teratogenesis, hypoosmolarity, skin disorders Lamotrigine: double or blurred vision, dizziness, headache, nausea, vomiting, serious skin rashes Valproate: nausea, vomiting, indigestion, hepatotoxicity, pancreatitis, thrombocytopenia, teratogenesis, weight gain
Antiepileptic drugs interactions
Use additional birth control; avoid grapefruit juice
A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make?
A. “That is a good choice. Ibuprofen does not interact with lithium.”
B. “Regular aspirin would be a better choice than ibuprofen.”
C. “Lithium decreases the effectiveness of ibuprofen.”
D. “The ibuprofen will make your lithium level fall too low.”
B. Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk for lithium toxicity.
A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (Select all that apply)
A. Constipation
B. Polyuria
C. Rash
D. Muscle weakness
E. Tinnitus
B & D. Polyuria and muscle weakness are early signs of lithium toxicity. Diarrhea is an early indication, not constipation. Tinnitus is an indication of severe toxicity. Lithium toxicity does not cause rash.
A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following?
A. AST/ALT and LDH
B. Creatinine and BUN
C. WBC and granulocyte counts
D. Serum sodium and potassium
A. Routine monitoring of liver function tests is necessary due to the risk for hepatotoxicity. Routine monitoring of the others is not necessary.
A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client’s lithium blood level 1.2 mEq/L. Which of the following actions should the nurse take?
A. Administer the next dose of lithium carbonate as scheduled.
B. Prepare for administration of aminophylline.
C. Notify the provider for a possible increase in the dosage of lithium carbonate.
D. Request a stat repeat of the client’s lithium blood level.
A. During a manic episode, the lithium blood level should be 0.8-1.4 mEq/L. It is appropriate to administer the next dose as scheduled.
A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client’s adult daughter, which of the following statements is the priority to report to the provider?
A. “My mother has diabetes that is controlled by her diet.”
B. “My mother recently completed a course of prednisone for acute bronchitis.”
C. “My mother received her flu vaccine last month.”
D. “My mother is currently on furosemide for her congestive heart failure.”
D. Diuretics, such as furosemide, are contraindicated for use with lithium due to the risk for toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider.
First generation (conventional) antipsychotics
Chlorpromazine (low potency), haloperidol (high potency), fluphenazine (high potency), loxapine (medium potency), thioridazine (low potency), thiothixene (high potency), perphenazine (medium potency), trifluoperazine (high potency); block dopamine, acetylcholine, histamine, and norepinephrine receptors; avoid alcohol and other CNS depressants and hazardous activities
Side effects of first gen antipsychotics
Agranulocytosis, anticholinergic effects (dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia), EPS, neuroendocrine effects (gynecomastia, weight gain, menstrual irregularities), neuroleptic malignant syndrome (sudden high fever, BP changes, diaphoresis, tachycardia, muscle rigidity, drooling, decreased LOC, coma, tachypnea), orthostatic hypotension, sedation, seizures, severe dysrhythmias, sexual dysfunction, skin effects, liver impairment
Extrapyramidal side effects
Acute dystonia (severe spasm of the tongue, neck, face, and back), pseudoparkinsonism (bradykinesia, rigidity, shuffling gait, drooling, tremors), akathisia (inability to sit or stand still), tardive dyskinesia (involuntary movements of the tongue and face, arms, legs, and trunk)
Second and third generation (atypical) antipsychotics
Risperidone, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, ziprasidone, aripiprazole (third gen); block serotonin and, to a lesser degree, dopamine receptors; treat positive and negative symptoms of schizophrenia; avoid alcohol and other CNS depressants and hazardous activities; should not be used with TCAs
Side effects of second and third gen antipsychotics
Metabolic syndrome, orthostatic hypotension, anticholinergic effects (urinary hesitancy or retention, dry mouth), agitation, dizziness, sedation, sleep disruption, mild EPS (tremor), elevated prolactin levels, sexual dysfunction
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription of which of the following medications?
A. Chlorpromazine
B. Thiothixene
C. Risperidone
D. Haloperidol
C. Second gen antipsychotics, such as risperidone, are effective in treating negative symptoms of schizophrenia, such as lack of grooming and flat affect. A, B, & D are first gen antipsychotics that are used mainly to control positive symptoms of schizophrenia.
A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change in which of the following medications? (Select all that apply)
A. Olanzapine
B. Quetiapine
C. Aripiprazole
D. Clozapine
E. Asenapine
C, D, & E. Aripiprazole and clozapine are available in orally disintegrating tablets which are appropriate for clients who have difficulty swallowing tablets. Asenapine is available in a sublingual tablet which is appropriate for clients who have difficulty swallowing tablets.
A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first generation antipsychotics? (Select all that apply)
A. Auditory hallucinations
B. Withdrawal from social situations
C. Delusions of grandeur
D. Severe agitation
E. Anhedonia
A, C, & D. Positive symptoms of schizophrenia such as auditory hallucinations, delusions of grandeur, and severe agitation are treated with first gen antipsychotics. B & E are negative symptoms and are best treated with second gen antipsychotics.
A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply)
A. Decreased LOC
B. Drooling
C. Involuntary arm movements
D. Urinary retention
E. Continual pacing
B, C, & E. Drooling, involuntary arm movements, and continual pacing are EPS.
A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding of the teaching?
A. “I will be able to stop taking this medication as soon as I feel better.”
B. “If I feel drowsy during the day, I will stop taking this medication and call my provider.”
C. “I will be careful not to gain too much weight while taking this medication.”
D. “This medication is highly addictive and must be withdrawn slowly.”
C. Antipsychotic meds, such as iloperidone, have a high risk for significant weight gain. Antipsychotic meds are long term treatment. Drowsiness is not a reason to discontinue the med. Antipsychotic meds are not considered addictive.
CNS stimulants
Methylphenidate, amphetamine mixture, dextroamphetamine; used to treat ADHD in children and adults; should not be used with MAOIs, caffeine, alcohol, or OTC cold and decongestant meds; oral med should be taken 30-45 min before meals with the last dose given by 4 pm
Side effects of CNS stimulants
Insomnia, restlessness, weight loss related to reduced appetite, growth suppression, cardiovascular effects, development of psychotic manifestations, withdrawal reaction, hypersensitivity skin reaction to transdermal methylphenidate (hives, papules)
Atomoxetine
SNRI used to treat ADHD in children and adults; should not be used with MAOIs, OTC meds, or alcohol; use with caution if taken with SSRIs
Side effects of atomoxetine
Appetite/growth suppression, weight loss, nausea, vomiting, upper abdominal pain, suicidal ideation, hepatotoxicity, headache, insomnia irritability
Desipramine, imipramine, clomipramine
TCAs used to treat depression, autism spectrum disorder, ADHD, panic disorder, separation anxiety disorder, social phobia, school phobia, and OCD in children; contraindicated in clients who have seizure disorders; should not be used with MAOIs, antihistamines, anticholinergic agents, alcohol, benzodiazepines, and opioids
Side effects of desipramine, imipramine, and clomipramine
Orthostatic hypotension, anticholinergic effects (dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia), weight gain related to increased appetite, sedation, toxicity (dysrhythmias, mental confusion, agitation), decreased seizure threshold, excessive sweating
Alpha2-adrenergic agonists
Guanfacine, clonidine; used to treat ADHD; extended release clonidine is contraindicated for children younger than 6 years old; should not be used with CNS depressants, alcohol, antihypertensives, or foods with high-fat content
Side effects of alpha agonists
Sedation, drowsiness, fatigue, hypotension, bradycardia, weight gain, nausea, vomiting, constipation, dry mouth
A nurse is teaching the parents of a child who has autism spectrum disorder and a new prescription for imipramine about indications of toxicity. Which of the following should the nurse include in the teaching? (Select all that apply)
A. Seizures
B. Agitation
C. Photophobia
D. Dry mouth
E. Irregular pulse
A, B, & E. Seizures, agitation, and irregular pulse are indications of TCA toxicity. Photophobia and dry mouth are anticholinergic effects.
A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide?
A. Eat a diet high in fiber
B. Check temperature daily
C. Take medication first thing in the morning before eating
D. Add extra calories to the diet as between-meal snacks
A. Eating a diet high in fiber will decrease constipation, an anticholinergic effect associated with TCA use. Checking temp daily is unnecessary. The med should be taken at bedtime. Following a well-balanced diet plan rather than adding extra calories as snacks will help prevent weight gain.
A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? (Select all that apply)
A. Somnolence
B. Yellowing skin
C. Increased appetite
D. Fever
E. Malaise
B, D, & E. Yellowing skin, fever, and malaise are potential indications of hepatotoxicity that should be reported. Insomnia, rather than somnolence, is an adverse effect of atomoxetine. Decreased appetite is an adverse effect of atomoxetine.
A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication?
A. Apply the patch once daily at bedtime
B. Place the patch carefully in a trash can after removal
C. Apply the transdermal patch to the anterior waist area
D. Remove the patch each day after 9 hr
D. The transdermal patch is applied once daily in the morning and is removed after 9 hr. The patch should be folded and flushed down the toilet to discard. The patch should be applied to a clean, dry area on the hip, the waist area should be avoided.
A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (Select all that apply)
A. An adverse effect of this medication is CNS depression
B. Administer the medication in the morning
C. Monitor for weight loss while taking this medication
D. Therapeutic effects of this medication will take 1-3 weeks to fully develop
E. This medication blocks the synaptic reuptake of serotonin in the brain.
B, C, & E. Fluoxetine should be administered in the morning to avoid insomnia, can result in weight loss, and blocks the synaptic reuptake of serotonin. An adverse effect of fluoxetine is CNS stimulation rather than CNS depression. Fluoxetine takes 4 weeks to fully develop therapeutic effects.
Medications for abstinence withdrawal
Benzodiazepines (chlordiazepoxide, diazepam, lorazepam, oxazepam) and adjunct medications (carbamazepine, clonidine, propranolol, atenolol)
Intended effects of benzodiazepines for alcohol withdrawal
Maintenance of vitals, decrease in the risk of seizures, decrease in the intensity of withdrawal manifestations, and substitution therapy during alcohol withdrawal
Intended effects of adjunct medications for alcohol withdrawal
Decrease in seizures (carbamazepine), decrease of autonomic response (clonidine, propranolol, atenolol), and decrease in craving (propranolol, atenolol)
Disulfiram
Daily oral med used for alcohol aversion therapy; concurrent use with alcohol will cause acetaldehyde syndrome (nausea, vomiting, weakness, sweating, palpitations, hypotension); avoid any products that contain alcohol (cough syrup, aftershave lotion, mouthwash, hand sanitizer, vanilla extract)
Naltrexone
Pure opioid antagonist that suppresses the craving and pleasurable effects of alcohol, also used for opioid withdrawal; concurrent use with opioids increases the risk for overdose of opiates; take with meals to decrease GI distress
Acamprosate
Taken orally 3x a day to reduce the unpleasant effects of alcohol abstinence (dysphoria, anxiety, restlessness); diarrhea may result, maintain adequate fluid intake; avoid use in pregnancy
Methadone substitution
Oral opioid agonist that replaces the opioid to which the client has a physical dependence; prevents abstinence syndrome from occurring and removes the need to obtain illegal opioids; used for withdrawal and long term maintenance; must be slowly tapered; must be administered from an approved treatment center
Clonidine
Assists with opioid withdrawal effects related to autonomic hyperactivity (diarrhea, nausea, vomiting) but does not reduced the craving; avoid activities that require mental alertness until drowsiness subsides; encourage the client to chew sugarless gum, suck on hard candy, sip on small amounts of water, or suck on ice chips to treat dry mouth
Buprenorphine
Agonist-antagonist opioid used for both withdrawal and maintenance; decreases feelings of craving and can be effective in maintaining compliance; can be prescribed by a primary care provider
Nicotine replacement therapy
Nicotine gum, patch, nasal spray, lozenges, or inhaler; substitute for the nicotine in cigarettes or chewing tobacco; doubles the rate of tobacco cessation
Nicotine replacement therapy client education
Chew nicotine slowly and intermittently over 30 min; avoid eating or drinking 15 min prior to and while chewing nicotine gum or lozenges; do not use nicotine gum longer than 6 months; avoid using any nicotine products while wearing the patch; remove patch prior to MRI; allow lozenges to slowly dissolve in the mouth (20-30 min)
Varenicline
Nicotinic receptor agonist that promotes the release of dopamine simulate the pleasurable effects of nicotine; reduces cravings for nicotine as well as the severity of withdrawal manifestations; reduces incidence of relapse; take after a meal; can cause neuropsychiatric effects (unpredictable behavior, mood changes, thoughts of suicide); banned for use in clients who are commercial truck or bus drivers, air traffic controllers, or airplane pilots
A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching?
A. “This medication will help prevent seizures during alcohol withdrawal.”
B. “Taking this medication will decrease your cravings for alcohol.”
C. “This medication maintains your blood pressure at a normal level during alcohol withdrawal.”
D. “Taking this medication will improve your ability to maintain abstinence from alcohol.”
A. Carbamazepine is used during withdrawal to decrease the risk for seizures. Carbamazepine promotes safe withdrawal rather than a decrease in cravings or abstinence. Clonidine and propranolol are used to maintain BP.
A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should anticipate prescriptions for which of the following medications to promote long-term abstinence from alcohol? (Select all that apply)
A. Lorazepam
B. Diazepam
C. Disulfiram
D. Naltrexone
E. Acamprosate
C, D, & E. Disulfiram promotes abstinence through aversion therapy. Naltrexone promotes abstinence by suppressing the craving and pleasurable effects. Acamprosate decreases the unpleasant effects resulting from abstinence. A & B are prescribed for short-term use during withdrawal.
A nurse is evaluating a client’s understanding of a new prescription for clonidine for the treatment or opioid use disorder. Which of the following statements by the client indicates an understanding of the teaching?
A. “Taking this medication will help reduce my craving for heroin.”
B. “While taking this medication, I should keep a pack of sugarless gum.”
C. “I can expect some diarrhea from taking this medicine.”
D. “Each dose of this medication should be placed under my tongue to dissolve.”
B. Clonidine commonly causes clients to experience dry mouth. Chewing sugarless gum is an effective method to address this adverse effect. Clonidine does not reduce cravings, but reduces diarrhea. Buprenorphine is administered sublingually.
A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply)
A. “Methadone is a replacement for physical dependence to opioids.”
B. “Methadone reduces the unpleasant effects associated with abstinence syndrome.”
C. “Methadone can be used during opioid withdrawal and to maintain abstinence.”
D. “Methadone increases the risk for acetaldehyde syndrome.”
E. “Methadone must be prescribed and dispensed by an approved treatment center.”
A, B, C, & E. Methadone replaced the opioid the client is dependent on, prevents abstinence syndrome from occurring, is used for both withdrawal and long-term maintenance, and must be prescribed by an approved treatment center. Disulfiram places the client at risk acetaldehyde syndrome.
A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse include in the teaching?
A. Chew the gm for no more than 10 min.
B. Rinse out the mouth immediately before chewing the gum.
C. Avoid eating 15 min prior to chewing the gum.
D. Use of the gum is limited to 90 days.
C. The client should avoid eating or drinking 15 min prior to and while chewing the gum. The gum should be chewed gradually over 30 min. Use of the gum is not recommended for longer than 6 months.
Necessary loss
Part of the cycle of life, anticipated but can still be intensely felt
Actual loss
Any loss of a valued person or item
Perceived loss
Any loss defined by a client that is not obvious to others
Maturational loss
Losses normally expected due to the developmental processing of life
Situational loss
Unanticipated loss caused by an external event
Numbness or protest (Bowlby stage of grief)
Client is in denial over the reality of the loss and experiences feelings of shock
Disequilibrium (Bowlby stage of grief)
Client focuses on the loss and has an intense desire to regain what was lost
Disorganization and despair (Bowlby stage of grief)
Client feels hopelessness which impacts the client’s ability to carry out tasks of daily living
Reorganization (Bowlby stage of grief)
Client reaches acceptance of the loss
Shock and disbelief (Engel stage of grief)
Client experiences a sense of numbness and denial over the loss
Developing awareness (Engel stage of grief)
Client becomes aware of the reality of the loss resulting in intense feelings of grief, this begins within hours of the loss
Restitution (Engel stage of grief)
Client carries out cultural/religious rituals, such as funeral, following the loss
Resolution of the loss (Engel stage of grief)
Client is preoccupied with the loss, over about a 12 month time period this preoccupation gradually decreases
Recovery (Engel stage of grief)
Client moves past the preoccupation and forward with life
Worden: Four Tasks of Mourning
Task I: accepting the reality of the loss Task II: processing the pain of grief Task III: adjusting to a world without the lost entity Task IV: finding an enduring connection with the lost entity in the midst of embarking on a new life
Delayed or inhibited grief
Client does not demonstrate the expected behaviors of the normal grief process
Distorted or exaggerated grief response
Client experiences the feelings and somatic manifestations associated with normal grief but to an exaggerated level
Chronic or prolonged grief
Difficult to identify due to varying lengths or time required by clients to work through the stages/tasks of grief; can remain in the denial stage and remain unable to accept the reality of the loss; can result in the client’s inability to perform activities of daily living
A nurse is caring for a client following the loss of her partner due to a terminal illness. Identify the sequence of Engel’s five stages of grief that the nurse should expect the client to experience. (Select the stages of grief in the order of occurrence. All steps must be used.)
A. Developing awareness
B. Restitution
C. Shock and disbelief
D. Recovery
E. Resolution of the loss
Step 1: C. Shock and disbelief Step 2: A. Developing awareness Step 3: B. Restitution Step 4: E. Resolution Step 5: D. Recovery
A charge nurse is reviewing Kugler-Ross: Five Stages of Grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply)
A. Disequilibrium
B. Denial
C. Bargaining
D. Anger
E. Depression
B, C, D, & E. Denial, bargaining, anger, and depression are stages of the Kulber-Ross five stages of grief. Disequilibrium is the second stage of Bowlby’s four stages of grief.
A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence a client’s grief and coping ability? (Select all that apply)
A. Interpersonal relationships
B. Culture
C. Birth order
D. Religious beliefs
E. Prior experience with loss
A, B, D, & E. Interpersonal relationships, culture, religious beliefs, and prior experience with loss influence a client’s grief and coping ability. Birth order does not influence a client’s grief and coping ability.
A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply)
A. “I may experience feelings of resentment.”
B. “I will probably withdraw from others.”
C. “I can expect to experience changes in sleep.”
D. “It is possible that I will experience suicidal thoughts.”
E. “It is expected that I will have a loss of self-esteem.”
A, B, & C. Resentment, withdrawal, and somatic manifestations are associated with normal grief. Suicidal ideations and loss of self-esteem are associated with maladaptive grief.
A nurse is caring for a client who lost his mother to cancer last month. The client states, “I’d still have my mother if the doctor would have diagnosed her sooner.” Which of the following responses should the nurse make?
A. “You sound angry. Anger is a normal feeling associated with loss.”
B. “I think you would feel better if you talked about your feelings with a support group.”
C. “I understand just how you feel. I felt the same when my mother died.”
D. “Do other members of your family also feel this way?”
A. This response acknowledges the client’s emotion and provides education on the normal grief response. B offers advice. C minimizes the client’s feelings. D takes the focus away from the client.
Oppositional defiant disorder
Characterized by a recurrent pattern of the following antisocial behaviors: negativity, disobedience, hostility, defiant behaviors (especially toward authority figures), stubbornness, argumentativeness, limit testing, unwillingness to communicate, and refusal to accept responsibility for misbehavior
Disruptive mood dysregulation disorder
Onset is between ages 6-28; clients who have this disorder exhibit recurrent temper outbursts that are severe and do not correlate with the situation; temper outbursts are manifested verbally and/or physically and can include aggression, are not appropriate for the client’s developmental level, are present 3 or more times per week, and are observable by others
Intermittent explosive disorder
Occurs in clients 18 years and older; clients who have this disorder exhibit recurrent episodic violent and aggressive behavior with the possibility of hurting people, property, or animals
Conduct disorder
Clients who have this disorder demonstrate a persistent pattern of behavior that violates the rights of others or rule and norms of society; categories of conduct disorder include aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules; child onset occurs before 10 years, adolescent onset occurs after 10 years
A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply)
A. Allow the child to choose consequences for negative behavior
B. Use role-playing to act out unacceptable behavior
C. Develop a reward system for acceptable behavior
D. Encourage the child to participate in school sports
E. Be consistent when addressing unacceptable behavior
C, D, & E. The parents should have a method to reward the child for acceptable, encourage physical activity, and set clear limits on unacceptable behavior.
A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following manifestations should the nurse expect (Select all that apply)
A. Fear of being alone
B. Substance use
C. Weight gain
D. Irritability
E. Aggressiveness
B, D, & E. Substance, irritability, and aggressiveness are expected findings associated with depression. Solitary play and weight loss are expected findings of depression.
A nurse is obtaining a health history from the parents of a 12 year old client who has conduct disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Bullying of others
B. Threats of suicide
C. Law-breaking activities
D. Narcissistic behavior
E. Flat affect
A, B, & C. Bullying behavior, suicidal ideation, and law and/or rule breaking are expected findings of conduct disorder. Low self-esteem and irritability/temper outbursts are expected findings of conduct disorder.
A nurse in a pediatric clinic is caring for a preschool-age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching?
A. “Behaviors associated with ADHD are present prior to age 3.”
B. “This disorder is characterized by argumentativeness.”
C. “Below-average intellectual functioning is associated with ADHD.”
D. “Because of this disorder, your child is at increased risk for injury.”
D. Inattentive or impulse behavior increases the risk for injury in a child who has ADHD. Behaviors associated with ADHD are present before the age of 12. Argumentativeness is associated with oppositional defiant disorder. Below-average intellectual functioning is associated with intellectual development disorder.
A nurse is assessing a 4-year-old child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess?
A. Impulsive behavior
B. Repetitive counting
C. Destructiveness
D. Somatic problems
B. Repetitive actions and strict routine are an indication of autism spectrum disorder. Impulsive behavior is an indication of ADHD. Destructiveness is an indication of conduct disorder. Somatic problems are an indication of PTSD.
Situational/external crisis
Often unanticipated loss or change experienced in every day, often unanticipated, life events
Maturational/internal crisis
Achieving new developmental stages, which requires learning additional coping mechanisms
Adventitious crisis
The occurrence of natural disaster or crimes; people in communities with large scale psychological trauma caused by natural disasters
Phase 1 of a crisis
Escalating anxiety from a threat activates increased defense responses
Phase 2 of a crisis
Anxiety continues escalating as defense responses fail, functioning becomes disorganized, and the client resorts to trial-and-error attempts to resolve anxiety
Phase 3 of a crisis
Trial-and-error methods of resolution fail, and the client’s anxiety escalates to severe or panic levels, leading to flight or withdrawal behaviors
Phase 4 of a crisis
The client experiences overwhelming anxiety that can lead to anguish and apprehension, feelings of powerlessness and being overwhelmed, dissociative symptoms (depersonalization, detachment from reality), depression, confusion, and/or violence against others or self
Primary care of a crisis
Collaborate with client to identify potential problems; instruct on coping mechanisms; and assist in lifestyle changes
Secondary care of a crisis
Collaborate with client to identify interventions while in an acute crisis that promote safety
Tertiary care of a crisis
Collaborate with client to provide support during recovery from a severe crisis that include outpatient clinics, rehab centers, and workshops
A nurse is conducting chart reviews of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis?
A. Rape
B. Marriage
C. Severe physical illness
D. Job loss
B. Marriage is an example of a maturational crisis, which is a naturally occurring event during the life span. Rape is an example of an adventitious crisis. Severe physical illness and job loss are examples of situational crises.
A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (Select all that apply)
A. Lithium carbonate
B. Paroxetine
C. Risperidone
D. Haloperidol
E. Lorazepam
B & E. SSRIs and benzodiazepines may be prescribed to decrease the anxiety of a client experiencing a crisis. Mood stabilizers and antipsychotics are not useful in treating the anxiety of a client experiencing a crisis.
Primary interventions for suicide
Focus on suicide prevention through the use of community education and screenings to identify individuals at risk
Secondary interventions for suicide
Focus on suicide prevention for an individual client who is having an acute suicidal crisis; suicide precautions are included in this level
Tertiary interventions for suicide
Focus on providing support and assistance to survivors of a client who completed suicide
A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (Select all that apply)
A. “My family will be better off if I’m dead.”
B. “The stress in my life is too much to handle.”
C. “I wish my life was over.”
D. “I don’t feel like I can ever be happy again.”
E. “If I kill myself then my problems will go away.”
A, C, & E. Overt statements talk directly about the client’s perception of suicide and their wish to no longer be alive. B & D are covert statements.
A nurse is caring for a client who states, “I plan to commit suicide.” Which of the following assessments should the nurse identify as the priority?
A. Client’s educational and economic background
B. Lethality of the method and availability of means
C. Quality of the client’s social support
D. Client’s insight into the reasons for the decision
B. The greatest risk to the client is self-harm as a result of carrying out a suicide plan. The priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is.
A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (Select all that apply)
A. Conducting a suicide risk screening on all new clients
B. Creating a support group for family members of clients who completed suicide
C. Educating high school teens about suicide prevention
D. Initiating one-on-one observation for a client who has suicidal ideation
E. Teaching middle-school educators about warning indicators of suicide
A, C, & E. Primary interventions include suicide prevention through the use of screenings to identify individuals at risk and community education. B is tertiary intervention. D is secondary intervention.
A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?
A. Assign the client to a private room
B. Document the client’s behavior every hour
C. Allow the client to keep perfume in her room
D. Ensure that the client swallows medication
D. Ensure that the client swallows medication to prevent hoarding of medication for an attempted overdose. Clients who are suicidal should not be assigned to a private room. Their behavior should be documented every 15 min. Perfume should be removed from the client’s room.
A nurse is conducting a class for a group of newly licensed nurses on caring for clients who at risk for suicide. Which of the following information should the nurse include in the teaching?
A. A client’s verbal threat of suicide is attention-seeking behavior
B. Interventions are ineffective for clients who really want to commit suicide
C. Using the term suicide increases the client’s risk for a suicide attempt
D. A no-suicide contract decreases the client’s risk for a suicide attempt
D. The use of a no-suicide contract decreases the client’s risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies. A, B, & C are myths.
Steps to handle aggressive behavior
Respond quickly, remain calm and in control, encourage the client to express feelings verbally, allow the client as much personal space as possible, maintain eye contact, sit or stand at the same level of the client, avoid accusatory or threatening statements, describe options clearly and offer choices, reassure the client that staff members are present to help prevent loss of control, set limits for the client
Medications to control aggressive and impulsive behaviors
Olanzapine and ziprasidone (atypical antipsychotics; haloperidol (antipsychotic); may also use SSRIs, mood stabilizers, and benzodiazepines
A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication?
A. “I wish you could not make me angry.”
B. “I feel angry when you leave me.”
C. “It makes me angry when you interrupt me.”
D. “You’d better listen to me.”
D. This implies a threat and a lack of respect for another individual. A, B, & C do not imply threats or indicate a lack of respect.
A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?
A. Insist that the client stop yelling
B. Request that other staff members remain close by
C. Move as close to the client as possible
D. Walk away from the client
B. The nurse should request that other staff members remain close by to assist if necessary. The nurse should not make demands of the client or walk away from an angry client. Clients who are angry need large personal space.
A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply)
A. Lethargy
B. Defensive responses to questions
C. Disorientation
D. Facial grimacing
E. Agitation
B, D, & E. Defensive responses, facial grimacing, and agitation are assessment findings that indicate a client is in the preassaultive stage. A is more likely to be observed in a client who has depression. C is more likely to be assessed in a client who has a cognitive disorder.
A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action?
A. Encourage the client to express her feelings
B. Maintain eye contact with the client
C. Move the client away from others
D. Tell the client that the behavior is not acceptable
C. The client’s behavior indicates that he is at greatest risk for harming others. The priority acton for the nurse is to move the client away from others.
A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client?
A. “Stop screaming, and walk with me outside.”
B. “Why are you so angry and screaming at everyone?”
C. “You will not get your way by screaming.”
D. “What was going through your mind when you started screaming?”
A. This sets limits and the use of physical activity, such as walking, to deescalate anger. B is a “why” question. C is a close-ended statement, which is nontherapeutic. The client is not ready to discuss this issue.
Characteristics of abusers
Possible use of threats and intimidation to control the vulnerable person, usually an extreme disciplinarian who believes in physical punishment, poor impulse control, perceives the child as bad, violent outbursts, poor coping skills, low self-esteem, feelings of worthlessness, possible of history of substance use disorder, difficulty assuming typical adult roles, likely to have experienced family violence as a child
A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of the teaching?
A. “Children older than 3 are at greater risk for abuse.”
B. “Substance use disorder does not increase the risk for violence.”
C. “Entering an intimate relationship increases the risk for violence.”
D. “Pregnancy increases the risk for violence toward the intimate partner.”
D. Pregnancy tends to increase the likelihood of violence toward the intimate partner. Children younger than 3 are at an increased risk for abuse. Substance use disorder increases the risk for violence. Vulnerable persons are at an increased risk for violence when they try to leave the relationship.
A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply)
A. Sunken fontanels
B. Respiratory distress
C. Retinal hemorrhage
D. Altered LOC
E. Increase in head circumference
B, C, D, & E. Respiratory distress, retinal hemorrhage, altered LOS, and increased head circumference are expected findings of shaken baby syndrome. Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome.
A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible abuse?
A. Abrasions on knees
B. Round burn marks on forearms
C. Mismatched clothing
D. Abdominal rebound tenderness
E. Areas of ecchymosis on torso
B & E. Round burn marks anywhere on the child’s body can indicate cigarette burns and should alert the nurse to possible abuse. Areas of ecchymosis on the torso, back, or buttocks should alert the nurse to possible abuse. Minor injuries on the arms and legs and mismatched clothing are common in this age group. Abdominal rebound tenderness is a possible indication or appendicitis rather than abuse.
A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?
A. Refusing to pay bills for a dependent, even when funds are available, is neglect.
B. Intentionally causing an older adult to fall is an example of physical violence.
C. Striking an intimate partner is an example of sexual violence.
D. Failure to provide a stimulating environment for normal development is emotional abuse.
B. Physical violence occurs when physical pain or harm is directed toward another individual. A is economic maltreatment. C is physical violence. D is neglect.
A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority?
A. Advise the client about the location of women’s shelters
B. Encourage the client to participate in a support group for survivors of abuse
C. Implement case management to coordinate community and social services
D. Educate the client about the use of stress management techniques
A. The greatest risk to this client is injury from intimate partner abuse. Therefore, the priority action the nurse should take is to assist the client with the development of a safety plan that includes the identification of safe places to live.
Rape trauma syndrome
Sustained and maladaptive response to a forced, violent sexual penetration against the individual’s will and consent, similar to PTSD; expressed reaction is overt and consists of emotional outbursts (crying, laughing, hysteria, anger, incoherence); controlled reaction is ambiguous; somatic reaction can occur later
Compound rape reaction
Some survivors of rape can experience additional disorders as a result of the sexual assault; mental health disorders (depression, substance use); physical disorders (manifestations of a prior physical illness)
Silent rape reaction
The survivor does not report or tell anyone of the sexual assault; abrupt changes in relationships with partners, nightmares, increased anxiety during interview, marked changes in sexual behavior, sudden onset of phobic reactions, no verbalization of the occurrence of sexual assault
A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction? (Select all that apply)
A. Sudden development of phobias
B. Development of substance use disorder
C. Increased level of anxiety during interview
D. Reactivation of a prior physical disorder
E. Unwillingness to discuss the sexual assault
A, C, & E. Sudden onset of phobic reactions, increased anxiety during interview, and not verbalizing the sexual assault are characteristics of a silent rape reaction. B and D are characteristics of a compound rape reaction.
A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply)
A. Genitourinary soreness
B. Difficulties with low self-esteem
C. Sleep disturbances
D. Emotional outburst
E. Difficulty making decisions
D & E. Emotional outbursts indicate an expressed initial reaction of rape-trauma syndrome. Difficulty making decisions indicates a controlled initial reaction of rape-trauma syndrome. A and C are somatic reactions. B is a sustained and maladaptive emotional response beyond the initial reaction.
A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “I will administer prophylactic treatment for sexually transmitted infections.”
B. “I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence.”
C. “I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder.”
D. “I should use narrative documentation when documenting subjective data.”
A. The nurse should administer prophylactic treatment for STIs. Informed consent is required before collecting forensic evidence. Manifestations of rape-trauma syndrome are similar to PTSD. The nurse should document subjective data using the client’s verbatim statements.
A nurse is caring for a client who was recently raped. The client states, “I never should have been out on the street alone at night.” Which of the following responses should the nurse make?
A. “Your actions had nothing to do with what happened.”
B. “You should focus on recovery rather than blaming yourself for what happened.”
C. “You believe this wouldn’t have happened if you hadn’t been out alone?”
D. “Why do you feel that you should not have been alone on the street at night?”
C. This response uses the therapeutic communication technique restating, which promotes reflection and verbalization of feelings. A offers opinion. B indicates disapproval. D is a “why” question.
A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?
A. “Rape is a crime of passion.”
B. “Acquaintance rape often involves alcohol.”
C. “Young adults are the typical victims of sexual assault.”
D. “The majority of rapists are unknown to the victims.”
B. Alcohol and other substances are often associated with date or acquaintance rape. Rape is a crime of violence, aggression, anger, and power. Individuals of all ages are affected by sexual assault and can be male or female. The majority of perpetrators are known to the vulnerable persons.