- D. An
interpreter will enable the nurse to better assess the client’s
problems and concerns. Nonverbal communication is important; however
for the nurse to fully determine the client’s problems and concerns,
the assistance of an interpreter is essential. The use of symbolic
pictures and universal phrases may assist the nurse in understanding
the basic needs of the client; however these are insufficient to assess
the client with a psychiatric problem.
- D. Psychoanalytic is
based on Freud’s beliefs regarding the importance of unconscious
motivation for behavior and the role of the id and superego in
opposition to each other. Behavioral cognitive and interpersonal
theories do not emphasize unconscious conflicts as the basis for
- D. By
acknowledging the observed behavior and asking the client to express
his feelings the nurse can best assist the client to become aware of
his anxiety. In option A, the nurse is offering an interpretation that
may or may not be accurate; the nurse is also asking a question that
may be answered by a “yes” or “no” response, which is not therapeutic.
In option B, the nurse is intervening before accurately assessing the
problem. Option C, which also encourages a “yes” or “no” response,
avoids focusing on the client’s anxiety, which is the reason for his
- A. A client
with obsessive-compulsive behavior uses this behavior to decrease
anxiety. Accepting this behavior as the client’s attempt to feel secure
is therapeutic. When a specific treatment plan is developed, other
nursing responses may also be acceptable. The remaining answer choices
will increase the client’s anxiety and therefore are inappropriate.
- A. Education
and work history would have the least significance in relation to the
client’s sexual problem. Age, health status, physical attributes and
relationship issues have great influence on sexual expression.
- C. Inpatient
treatment of a client with anorexia usually focuses initially on
establishing a plan for refeeding to combat the effects of self-induced
starvation. Refeeding is accomplished through behavioral therapy, which
uses a system of rewards and reinforcements to assist in establishing
weight restoration. Emphasizing nutrition and teaching the client about
the long-term physical consequences of anorexia maybe appropriate at a
later time in the treatment program. The nurse needs to assess the client’s mealtime behavior continually to evaluate treatment effectiveness.
- A. One of the
core issues concerning the family of a client with anorexia is control.
The family’s acceptance of the client’s ability to make independent
decisions is key to successful family intervention. Although the
remaining options may occur during the process of therapy they would
not necessarily indicate a successful outcome; the central family
issues of dependence and independence are not addressed in these
- D. The client
with a somatoform disorder displaces anxiety onto physical symptoms.
The ability to express anxiety verbally indicates a positive change
toward improved health. The remaining responses do not indicate any
positive change toward increased coping with anxiety.
- C. Directly
questioning a client about suicide is important to determine suicide
risk. The client may not bring up this subject for several reasons,
including guilt regarding suicide, wishing not to be discovered, and
his lack of trust in staff. Behavioral cues are important, but direct
questioning is essential to determine suicide risk. Indirect questions
convey to the client that the nurse is not comfortable with the subject
of suicide and, therefore, the client may be reluctant to discuss the
- C. A client
exhibiting flight of ideas typically has a continuous speech flow and
jumps from one topic to another. Speaking in coherent sentences is an
indicator that the client’s concentration has improved and his thoughts
are no longer racing. The remaining options do not relate directly to
the stated nursing diagnosis.
- C. The nurse
should take any nurse statements indicating suicidal thoughts seriously
and further assess for other risk factors. The remaining diagnoses fail
to address the seriousness of the client’s statement.
- D. This
statement provides accurate information and an element of hope for the
family of a schizophrenic client. Although the remaining statements are
true, they do not provide the empathic response the family needs after
just learning about the diagnosis. These facts can become part of the
- A. A client with schizophrenia, paranoid type,
has distorted perceptions and views people, institutions, and aspects
of the environment as plotting against him. The desired outcome for
someone with delusional perceptions would be to have a realistic
interpretation of daily events. The client with a distorted perception
of the environment would not necessarily have impairments affecting
hygiene and grooming skills. Although taking medications and
participating in unit activities may be appropriate outcomes for
nursing intervention, these responses are not related to client
- D. A client with these symptoms would have poor impulse control and would therefore be
prone to acting-out behavior that may be harmful to either himself or
others. All of the remaining nursing diagnoses may apply to the client
with mania; however, the priority diagnosis would be risk for violence.
- C. Rationalization is the defense mechanism
that involves offering excuses for maladaptive behavior. The client is
defending his substance abuse by providing reasons related to life
stressors. This is a common defense mechanism used by clients with
substance abuse problems. None of the remaining defense mechanisms
involves making excuses for behaviors.
- B. Physical
aggressiveness, low stress tolerance, and a disregard for the rights of
others are common behaviors in clients with conduct disorders.
Restlessness, short attention span, and hyperactivity are typical
behaviors in a client with attention deficit hyperactivity disorder.
Deterioration in social functioning, excessive anxiety and worry and
bizarre behaviors are typical in schizophrenic disorders. Sadness, poor
appetite, sleeplessness, and loss of interest in activities are
behaviors commonly seen in depressive disorders.
- B. Babies born
to heroin-dependent women are also heroin-dependent and need to go
through withdrawal. There is no evidence to support any of the
remaining answer choices.
Establishing an unbroken chain of evidence is essential in order to
ensure that the prosecution of the perpetrator can occur. The nurse
will also need to preserve the client’s privacy and identify the extent
of injury. However, it is essential that the nurse follow legal and
agency guidelines for preserving evidence. Identifying the assailant is
the job of law enforcement, not the nurse.
Socioeconomic status is not a reliable predictor of abuse in the home,
so it would be the least important consideration in deciding issues of
safety for the victim of family violence. The availability of
appropriate community shelters and the ability of the nonabusing
caretaker to intervene on the client’s behalf are important factors
when making safety decisions. The client’s response to possible
relocation (if the client is a competent adult) would be the most
important factor to consider; feelings of empowerment and being treated
as a competent person can help a client feel less like a victim.
- A. In the early stage of Alzheimer’s disease,
complex tasks (such as balancing a checkbook) would be the first
cognitive deficit to occur. The loss of self-care ability, problems
with relating to family members, and difficulty remembering one’s own
name are all areas of cognitive decline that occur later in the disease
- C. The client with Alzheimer’s disease
can have frequent episode of labile mood, which can best be handled by
decreasing a stimulating environment and redirecting the client’s
attention. An over stimulating environment may cause the labile mood,
which will be difficult for the client to understand. The client with
Alzheimer’s disease loses the cognitive ability to respond to either
humor or logic. The client lacks any insight into his or her own
behavior and therefore will be unaware of any causative factors.
- A. A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of Alzheimer’s disease will act to increase available acetylcholine in the brain. The remaining neurotransmitters have not been implicated in Alzheimer’s disease.
- C. The most
important factors to determine in this situations are the client’s
perception of the crisis event and the availability of support
(including family and friends) to provide basic needs. Although the
nurse should assess the other factors, they are not as essential as
determining why the client considers this a crisis and whether he can
meet his present needs.
- D. Crisis
intervention is based on the idea that a crisis is a disturbance in
homeostasis (steady state). The goal is to help the client return to a
previous level of equilibrium in functioning. The remaining answer
choices are not considered the primary outcome of crisis intervention,
although they may occur as a side benefit.
- B. Increased
anxiety and uncertainly characterize the initiation phase in group
therapy. Group members are more self-reliant during the working and
- A. As the
group progresses into the working phase, group members assume more
responsibility for the group. The leader becomes more of a facilitator.
Comments about behavior in a group are indicators that the group is
active and involved. The remaining answer choices would indicate the
group progress has not advanced to the working phase.
- C. The use of
diuretics would cause sodium and water excretion, which would increase
the risk of lithium toxicity. Clients taking lithium carbonate should
be taught to increase their fluid intake and to maintain normal intake
of sodium. Concurrent use of any of the remaining medications will not
increase the risk of lithium toxicity.
- D. In a
functional family, parents typically do not agree on all issues and
problems. Open discussion of thoughts and feeling is healthy, and
parental disagreement should not cause system stress. The remaining
answer choices are life transitions that are expected to increase
- A. Aged cheese and red
wines contain the substance tyramine which, when taken with an MAOI,
can precipitate a hypertensive crisis. The other foods and beverages do
not contain significant amounts of tyramine and, therefore, are not
- C. Because
chlorpromazine (Thorazine) can cause a significant hypotensive effect
(and possible client injury), the nurse must assess the client’s blood
pressure (lying, sitting, and standing) before administering this drug.
If the client had taken the drug previously, the nurse would also need
to assess the skin color and sclera for signs of jaundice, a possible
drug side affect; however, based on the information given here, there
is no evidence that the client has received chlorpromazine before.
Although the drug can cause urine retention, asking the client to avoid
will not alter this anticholinergic effect.
- B. The onset
of action of the SSRI antidepressant paroxetine occurs around 3 to 4
weeks after drug therapy begins. Therefore, a client will seldom notice
improvement before this time. Continuing to take the drug is important
for this client.
Over-the-counter medications used for allergies and cold symptoms are
contraindicated because they will increase the sympathomimetic effects
of MAOIs, possibly causing a hypertensive crisis. None of the remaining
medications will increase the sympathomimetic response and, therefore,
are not contraindicated.
- C. Urinary
retention is a common anticholinergic side effect of psychotic
medications, and the client with benign prostatic hypertrophy would
have increased risk for this problem. Adding fiber to one’s diet and
exercising regularly are measures to counteract another anticholinergic
effect, constipation. Depending on the specific medication and how it
is prescribed, taking the medication at night may or may not be
important. However, it would have nothing to do with urinary retention
in this client.
- B. Coffee
contains caffeine, which has a stimulating effect on the central
nervous system that will counteract the effect of the antianxiety
medication oxazepam. None of the remaining foods is contraindicated.
- B. The primary
purpose of Alcoholics Anonymous is to help members achieve and maintain
sobriety. Although each of the remaining answer choices may be an
outcome of attendance at Alcoholics Anonymous, the primary purpose is
directed toward sobriety of members.
- C. A therapeutic community
is designed to help individuals assume responsibility for themselves,
to learn how to respect and communicate with others, and to interact in
a positive manner. The remaining answer choices may be outcomes of
psychiatric treatment, but the use of a therapeutic community approach is concerned with promotion of self-reliance and cooperative adaptation to being with others.
- ADCBE. The
nurse should remain with the client to provide support and promote
safety. Reducing external stimuli, including dimming lights and
avoiding crowded areas, will help decrease anxiety. Encouraging the
client to use slow, deep breathing will help promote the body’s
relaxation response, thereby interrupting stimulation from the
autonomic nervous system. Encouraging physical activity will help him
to release energy resulting from the heightened anxiety state; this
should be done only after the client has brought his breathing under
control. Teaching coping measures will help the client learn to handle
anxiety; however, this can only be accomplished when the client’s panic
has dissipated and he is better able to focus.
- C. Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml
- C. The
initial, most basic assessment of a client with cognitive impairment
involves determining his level of orientation (awareness of time,
place, and person). The nurse may also assess for confabulation and
perseveration in a client with cognitive impairment; but the questions
in this situation would not elicit the symptom response. Delirium is a
type of cognitive impairment; however, other symptoms are necessary to
establish this diagnosis.
- D. Short words
and simple sentence minimize client confusion and enhance
communication. Complete explanations with multiple details and
stimulating words and phrases would increase confusion in a client with
short attention span and difficulty with comprehension. Although
pictures and gestures may be helpful, they would not substitute for
Confabulation is a communication device used by patients with dementia
to compensate for memory gaps. The remaining answer choices are
- C. Maintaining
a calm approach when intervening with an agitated client is extremely
important. Telling the client firmly that it is time to get dressed may
increase his agitation, especially if the nurse touches him. Restraints
are a last resort to ensure client safety and are inappropriate in this
situation. Sedation should be avoided, if possible, because it will
interfere with CNS functioning and may contribute to the client’s
- C. Sundowning
is a common phenomenon that occurs after daylight hours in a client
with a cognitive impairment disorder. The other options are incorrect
responses, although all may be seen in this client.
- D. Following
established activity schedules is a realistic expectation for clients
with dementia. All of the remaining outcome statements require a higher
level of cognitive ability than can be realistically expected of
clients with this disorder.
- C. The
family’s perception of the problem is essential because change in any
one part of a family system affects all other parts and the system as a
whole. Each member of the family has been affected by the current
problems related to the school system and the nurse would be interested
in the data. The child’s performance in school and the teacher’s
attempts to solve the problem are relevant and may be assessed;
however, priority would be given to the family’s perception of the
problem. The family education and work history may be relevant, but are
not a priority.
- B. Te parents
are feeling responsible and this inappropriate self-blame can be
limited by supplying them with the facts about the biologic basis of
schizophrenia. Acknowledging the patient’s responsibility is neither
accurate nor helpful to the parents and would only reinforce their
feelings of guilt. Support groups are useful; however, the nurse needs
to handle the parents’ self-blame directly instead of making a referral
for this problem. Teaching the parents various ways to change would
reinforce the parental assumption of blame; although parents can learn
about schizophrenia and what is helpful and not helpful, the approach
suggested in this option implies the parents’ behavior is at fault.
- A. Family
boundaries are parameters that define who is inside and outside the
system. The best method of obtaining this information is asking the
family directly who they consider to be members. The question asked by
the nurse would not elicit information about the family’s ethnicity or
culture, nor does it address the nature of the family relationship.
Differentiation is the process of becoming an individual developing
autonomy while staying in contact with the family system. Cooperative
action among family members does not refer to differentiation, although
individuals who have a high level of differentiation would be able to
accomplish cooperative action. Incongruent messages in which the
recipient is a victim describe double-bind communication. Maintenance
of system continuity or equilibrium is homeostasis.
- D. The nurse
who wishes to be helpful to the entire family must remain neutral.
Taking sides in a conflict situation in a family will not encourage
negotiation, which is important for problem resolution. If the nurse
aligned with the adolescent, then the nurse would be blaming the
parents for the child’s current problem; this would not help the
family’s situation. Learning to negotiate conflict is a function of a
healthy family. Encouraging the parents to adopt more realistic rules
or the adolescent to comply with parental rules does not give the
family an opportunity to try to resolve problems on their own.
- C. Enmeshment
is a fusion or overinvolvement among family members whereby the
expectation exists that all members think and act alike. The child who
always acts to please her parents is an example of how enmeshment
affects development in many cases, a child who develops anorexia nervosa exerts control only in the area of eating behavior. The remaining options are not appropriate to the situation described.