The nurse is reviewing the discharge plan with a female teenager with anorexia nervosa & reinforces the importance that the teenager attends a meeting of the local chapter of Anorexia Nervosa & Associated Disorders. Which response by the teenager indicates that she will likely be compliant with this plan? - ANS "I'm going to do whatever it takes to get better." Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply - ANS - Communicate expected behaviors to the client - Assist the client in developing means of setting limits on personal behavior. - Follow through about the consequences of behavior in a nonpunitive manner. - Be clear with the client regarding the consequences of exceeding limits set regarding behavior. The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 & began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which? - ANS Protection from the risk of intimacy A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image; the client reports an extreme fear of public speaking. The nurse analyzes this information & determines that the client's fear would be considered which diagnosis? - ANS A social phobia The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations & anxiety & determines that the client understands the interventions when the client states which? - ANS "I can call my therapist when I'm hallucinating so I can talk about my feelings & plans & not hurt anyone." A client has been brought to the ER after attempting to commit suicide by hanging. The nurse should take which nursing action first? - ANS Examine the neck area & assess the airway A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client? - ANS The client will stop blaming himself for the lack of insurance The RN has written an outcome statement of "Client will feel less anxious by the end of session" for a client with generalized anxiety disorder. Which interventions should the LPN use to assist this client in meeting this goal? Select all that apply. - ANS - Stay with the client - Administer anxiolytics medications if prescribed. - Ensure the client is in an environment with little stimuli. The nurse is reviewing the record of a client admitted to the mental health unit & notes that the client was admitted by voluntary status. The nurse makes which determination? - ANS The client has the right to demand & obtain release from the hospital A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder? - ANS Altered thought process The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? - ANS Opened ended questions & silence A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose? - ANS Disulfiram (Antabuse) The client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening & shouting at everyone, & is refusing to participate in therapy. The nurse takes which initial action? - ANS Provide for safety by recognizing the level of client anxiety and setting limits. The nurse enters a client's room, & the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was