Text Mode – Text version of the exam
1. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
- loose associations.
2. The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:
- give him privacy in the bathroom.
- allow him to shave.
- open the window and allow him to get some fresh air.
- observe him.
3. The nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan?
- Restrict visits with the family until the client begins to eat.
- Provide privacy during meals.
- Set up a strict eating plan for the client.
- Encourage the client to exercise, which will reduce her anxiety.
4. A client whose husband recently left her is admitted to the hospital with severe depression. The nurse suspects that the client is at risk for suicide. Which of the following questions would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk?
- “Are you sure you want to kill yourself?”
- “I know if my husband left me, I’d want to kill myself. Is that what you think?”
- “How do you think you would kill yourself?”
- “Why don’t you just look at the positives in your life?”
5. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates, such as morphine, include:
- dilated pupils and slurred speech.
- rapid speech and agitation.
- dilated pupils and agitation.
- euphoria and constricted pupils.
6. The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include:
- turning on the lights and opening the windows so that the client doesn’t feel crowded.
- leaving the client alone.
- staying with the client and speaking in short sentences.
- turning on stereo music.
7. The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for:
- a depressed client.
- a manic client.
- a suicidal client.
- an anxious client.
8. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:
- highly important or famous.
- being persecuted.
- connected to events unrelated to oneself.
- responsible for the evil in the world.
9. The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic stress disorder include:
- hyper alertness and sleep disturbances.
- memory loss of traumatic event and somatic distress.
- feelings of hostility and violent behavior.
- sudden behavioral changes and anorexia.
10. The nurse is caring for a client with manic depression. The care plan for a client in a manic state would include:
- offering high-calorie meals and strongly encouraging the client to finish all food.
- insisting that the client remain active throughout the day so that he’ll sleep at night.
- allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
- listening attentively with a neutral attitude and avoiding power struggles.
11. A client is a Vietnam War veteran with a diagnosis of posttraumatic stress disorder. He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief of his symptoms?
- The opportunity to verbalize memories of trauma to a sympathetic listener
- Family support
- Prescribed medications taken as ordered
- Alcoholics Anonymous (AA) meetings
12. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?
- Logical thinking
13. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping?
- Inability to make choices and decisions without advice
- Showing interest only in solitary activities
- Avoiding developing relationships
- Recurrent self-destructive behavior with history of depression
14. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:
- impending coma.
- manipulating behavior.
- perceptual disorders.
15. A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?
- Aggressive behavior
- Paranoid thoughts
- Emotional affect
- Independence needs
16. The nurse is caring for a client in an acute manic state. What’s the most effective nursing action for this client?
- Assigning him to group activities
- Reducing his stimulation
- Assisting him with self-care
- Helping him express his feelings
17. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
- avoid shopping for large amounts of food.
- control eating impulses.
- identify anxiety-causing situations.
- eat only three meals per day.
18. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
- Has perceptions based on reality
- Assumes responsibility for actions
- Generates new levels of awareness
- Has maximum ability to solve problems and learn new skills
19. A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect of lithium?
- Sexual dysfunction
20. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:
- tension and irritability.
- slow pulse.
21. During a shift report, the nurse learns that she’ll be providing care for a client who is vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as:
- antianxiety drugs.
22. A client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by:
- staying with the client until the attack subsides.
- telling the client everything is under control.
- telling the client to lie down and rest.
- talking continually to the client by explaining what’s happening.
23. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse’s best response at this time would be to:
- take the client’s vital signs.
- explore the content of the hallucinations.
- tell him his fear is unrealistic.
- engage the client in reality-oriented activities.
24. A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should:
- tell him that she’ll leave for now but will return soon.
- ask him if it’s okay if she sits quietly with him.
- ask him why he wants to be left alone.
- tell him that she won’t let anything happen to him.
25. A client begins taking haloperidol (Haldol). After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as:
- psychotic symptoms
26. The nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is:
- benztropine (Cogentin).
- diphenhydramine (Benadryl).
- propranolol (Inderal).
- haloperidol (Haldol).
27. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?
- Monthly blood tests will be necessary.
- Report a sore throat or fever to the physician immediately.
- Blood pressure must be monitored for hypertension.
- Stop the medication when symptoms subside.
28. A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?
29. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He’s shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?
- “I think you’re wrong. France is a friendly country and an ally of the United States. Their government wouldn’t try to kill you.”
- “I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.”
- “You’re wrong. Nobody is trying to kill you.”
- “A foreign government is trying to kill you? Please tell me more about it.”
30. A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which finding should alert the nurse that the client is experiencing pseudoparkinsonism?
- Restlessness, difficulty sitting still, pacing
- Involuntary rolling of the eyes
- Tremors, shuffling gait, mask like face
- Extremity and neck spasms, facial grimacing, jerky movements
31. A 54-year-old female was found unconscious on the floor of her bathroom with self-inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate?
- Observing for extrapyramidal symptoms
- Beginning a therapeutic relationship
- Canceling any no-suicide contracts
- Continuing suicide precautions
32. A 26-year-old male reports losing his sight in both eyes. He’s diagnosed as having a conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client?
- Not focusing on his blindness
- Providing self-care for him
- Telling him that his blindness isn’t real
- Teaching eye exercises to strengthen his eyes
33. A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?
- Provide an unstructured environment for the client.
- Rotate the nurses who are assigned to the client.
- Ignore the client’s behaviors.
- Bend unit rules to meet the client’s needs.
34. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:
- not occur at all because the time period for their occurrence has passed.
- begin anytime within the next 1 to 2 days.
- begin within 2 to 7 days.
- begin after 7 days.
35. Which of the following factors would have the most influence on the outcome of a crisis situation?
- Previous coping skills
- Perception of the problem
36. The nurse is caring for an elderly client in a long-term care facility. The client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first?
- Setting aside time to listen to the client
- Removing items that the client could use in a suicide attempt
- Communicating a nonjudgmental attitude
- Referring the client to a mental health professional
37. The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder?
- Wearing tight-fitting clothing
- Increased blood pressure
- Oily skin
- Excessive and ritualized exercise
38. A high school student is referred to the school nurse for suspected substance abuse. Following the nurse’s assessment and interventions, what would be the most desirable outcome?
- The student discusses conflicts over drug use.
- The student accepts a referral to a substance abuse counselor.
- The student agrees to inform his parents of the problem.
- The student reports increased comfort with making choices.
39. The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child:
- internalize his feelings about death and dying.
- accept responsibility for his situation.
- express feelings that he can’t articulate.
- have a good time while he’s in the hospital.
40. The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client?
- Abstinence is the basis for successful treatment.
- Attendance at Alcoholics Anonymous (AA) meetings every day will cure alcoholism.
- For treatment to be successful, family members must participate.
- An occasional social drink is acceptable behavior for the alcoholic.
41. One staff member in a psychiatric unit says to the nurse, “Why are we carrying out suicide precautions for someone who is dying? It’s pointless and a waste of time.” The nurse should:
- Assign the staff member to other clients.
- Ask the psychiatric clinical nurse specialist to meet with the staff member.
- Agree with the staff member and discontinue suicide precautions.
- Call for a multidisciplinary staff meeting.
42. The client with dual diagnoses of major depression and alcohol abuse states, “I only drink when I can’t sleep.” An initial outcome for this client is that the client will:
- Describe adaptive methods of coping to induce sleep.
- Verbalize negative effects of alcohol on the body.
- Describe dangerous effects when combining alcohol and antidepressant medication.
- Verbalize the desire to stop drinking alcohol.
43. The nurse will conduct a psycho educational group for family members about depression. Which of the following topics would be of little help to the family members?
- Managing the depressed client at home.
- Drug classifications.
- Support and self-help groups.
- Education about depression.
44. In teaching a client about Alcoholics Anonymous, the nurse states that Alcoholics Anonymous has helped in the rehabilitation of many alcoholics, probably because many people find it easier to change their behavior when they:
- Have the support of rehabilitated alcoholics.
- Know that rehabilitated alcoholics will sympathize with them.
- Can depend on rehabilitated alcoholics to help them identify personal problems related to alcoholism.
- Realize that rehabilitated alcoholics will help them develop defense mechanisms to cope with their alcoholism.
45. A client walks into the mental health clinic and states to the nurse, “I guess I can’t make it without my wife. I can’t even sleep without her.” Which of the following responses by the nurse would be most therapeutic?
- “Things always look worse before they get better.”
- “I’d say that you’re not giving yourself a fair chance.”
- “I’ll ask the doctor for some sleeping pills for you.”
- “Tell me more about what you mean when you say you can’t make it without your wife.”
46. During the conversation with the nurse, a victim of physical abuse says, “Let me try to explain why I stay with my husband.” Which of the following reasons would the client be LEAST likely to mention?
- “I’m responsible for keeping my family together.”
- “When it’s not too bad, the abuse adds spice to our relationship.”
- “I love my husband.”
- “I’m not sure I could get a job that pays even minimum wage.”
47. During a home visit, the client tells the nurse she’s not taking prescribed doses of haloperidol (Haldol) because she’s tired of bothering with it and doesn’t need it. The nurse’s best action is to:
- Explain the negative effects of skipping the medication.
- Consult with the physician about changing the medication to haloperidol decanoate (Haldol Decanoate) injections.
- Have the client’s family begin commitment procedures so that her medication regimen can be supervised more closely.
- Refer the client to a partial hospitalization program so that she can participate regularly in group therapy sessions.
48. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse:
- Gives the medication as ordered.
- Questions the physician about the order.
- Questions the dosage ordered.
- Asks the physician to order benztropine (Cogentin) for the side effects.
49. A voluntary client has been taking haloperidol (Haldol) as prescribed. One morning, she refuses to take the Haldol. Which of the following actions should the nurse take?
- Summon another nurse to help ensure that the client takes her medicine.
- Tell the client that she can take the medication either orally or by injection.
- Withhold the medication until it is determined why the client is refusing to take it.
- Tell the client that she needs to take her “vitamin” to stay healthy.
50. The client is taking fluoxetine (Prozac) 20 mg at bedtime. He states that Prozac is not helping him to sleep. The nurse judges:
- That the client should take Prozac in the morning.
- That dose is too high.
- That the client’s symptoms of depression seem to be getting worse.
- That the client is on the wrong medication.
Answers and Rationales
- B. hallucinations.Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client.
- D. observe him.The nurse has a responsibility to observe continuously the acutely suicidal client & not provide privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse will naturally prevent hanging or other injury. The nurse will check the client’s area and fix dangerous conditions, such as exposed pipes and windows without safety glass. The nurse will also remove potentially dangerous objects, such as belts, razors, suspenders, glass, and knives.
- C. Set up a strict eating plan for the client. Establishing a consistent eating plan and monitoring the client’s weight are important for this disorder. The family should be included in the client’s care. The client should be monitored during meals & not given privacy. Exercise must be limited and supervised.
- C. “How do you think you would kill yourself?” To determine if a client is at risk for suicide, ask, “How do you think you would kill yourself?” If the client has a plan, she may be closer to carrying out the act. Option a requires a yes-or-no response and is self-limiting. In Option b, the nurse is telling the client what to think and feel. Option d dismisses the client’s feelings.
- D. euphoria and constricted pupils.Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.
- C. staying with the client and speaking in short sentences. Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client’s anxiety.
- B. a manic client. Setting limits for unacceptable behavior is most important in a manic client. Typically, depressed, anxious, or suicidal clients don’t physically or mentally test the limits of the caregiver.
- A. highly important or famous. A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world.
- A. hyper alertness and sleep disturbances. Signs and symptoms of posttraumatic stress disorder include hyperalertness, sleep disturbances, exaggerated startle, survival guilt, and memory impairment. Also, the client relives the traumatic event through dreams and recollections. Hostility, violent behavior, and anorexia aren’t usual signs or symptoms of posttraumatic stress disorder.
- D. listening attentively with a neutral attitude and avoiding power struggles. The nurse should listen to the client’s requests, express willingness to seriously consider the requests, and respond later. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn’t try to restrain the client when he feels the need to move around as long as his activity isn’t harmful. High-calorie finger foods should be offered to supplement the client’s diet, if he can’t remain seated long enough to eat a complete meal. The client shouldn’t be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice.
- A. The opportunity to verbalize memories of trauma to a sympathetic listener. Although it’s difficult, clients with posttraumatic stress disorder can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. Family members are commonly frightened by the information and can’t be consistently supportive. Antidepressants may help but these drugs can mask feelings and can’t provide lasting relief. Treatment for alcohol abuse, including AA meetings, must be considered when planning care but alone doesn’t provide lasting relief.
- D. Denial. Denial is an unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association.
- A. Inability to make choices and decisions without advice . Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don’t show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren’t met, this isn’t a typical response.
- D. perceptual disorders. Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn’t an immediate consequence. Manipulative behaviors are part of the alcoholic client’s personality but not a sign of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.
- B. Paranoid thoughts. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships.
- B. Reducing his stimulation. Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, these clients aren’t able to express their inner feelings in a productive, introspective manner. The focus of treatment for a client in the manic state is behavior control.
- C. identify anxiety-causing situations. Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn’t a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn’t a realistic goal early in treatment.
- C. Generates new levels of awareness. Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development & not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30.
- C. Polyuria. Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. Sexual dysfunction isn’t a common adverse effect of lithium; it’s more common with sedatives and tricyclic antidepressants. Diarrhea, not constipation, occurs with lithium. Constipation can occur with other psychiatric drugs, such as antipsychotic drugs. Seizures may be a later sign of lithium toxicity.
- A. tension and irritability. An amphetamine is a nervous system stimulant that’s subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.
- C. antianxiety drugs. Antianxiety drugs provide symptomatic relief. Barbiturates and amphetamines can precipitate panic attacks. Depressants aren’t appropriate for treating panic attacks.
- A. staying with the client until the attack subsides. The nurse should remain with the client until the attack subsides. If the client is left alone, he may become more anxious. Giving false reassurance is inappropriate in this situation. The client should be allowed to move around and pace to help expend energy. The client may be so overwhelmed that he can’t follow lengthy explanations or instructions, so the nurse should use short phrases and slowly give one direction at a time.
- B. explore the content of the hallucinations. Exploring the content of the hallucinations will help the nurse understand the client’s perspective on the situation. The client shouldn’t be touched, such as in taking vital signs, without telling him exactly what’s going to happen. Debating with the client about his emotions isn’t therapeutic. When the client is calm, engage him in reality-based activities.
- A. tell him that she’ll leave for now but will return soon. If the client tells the nurse to leave, the nurse should leave but let the client know that she’ll return so that he doesn’t feel abandoned. Not heeding the client’s request can agitate him further. Also, challenging the client isn’t therapeutic and may increase his anger. False reassurance isn’t warranted in this situation.
- D. dystonia. These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.
- A. benztropine (Cogentin). Benztropine, trihexyphenidyl, or amantadine is prescribed for a client with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms.
- B. Report a sore throat or fever to the physician immediately. A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/ml, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician.
- C. Sodium. Lithium is chemically similar to sodium. When sodium levels are reduced, such as from sweating or diuresis, lithium is reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn’t restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions, but sodium is most important to the absorption of lithium.
- B.”I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.” Responses should focus on reality while acknowledging the client’s feelings. Arguing with the client or denying his belief isn’t therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.
- C. Tremors, shuffling gait, mask like face. Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and pill rolling. Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing.
- D. Continuing suicide precautions. As antidepressants begin to take effect and the client feels better, she may have the energy to initiate and complete another suicide attempt. As the client’s energy level increases, the nurse must continue to be vigilant to the risk of suicide. Extrapyramidal symptoms may occur with antipsychotics and aren’t adverse effects of antidepressants. A therapeutic relationship should be initiated upon admission to the psychiatric unit, after suicide precautions have been instituted. It’s through this relationship that the client develops feelings of self-worth and trust and problem-solving takes place. In a no-suicide contract, the client states verbally or in writing that she won’t attempt suicide and will seek out staff if she has suicidal thoughts. When the time period for a contract has expired, a new contract should be obtained from the client.
- A. Not focusing on his blindness. Focusing on the client’s blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own self-care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren’t under the client’s control and are real to him. Eye exercises won’t resolve the client’s blindness because no organic pathology is causing the symptoms.
- B. Rotate the nurses who are assigned to the client. Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting behaviors and her fear of abandonment. Firm rules and consistency among staff members will help control the client’s behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior.
- B. begin anytime within the next 1 to 2 days. Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days & even up to 7 days & after the last drink.
- B. Previous coping skills. Coping is a process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic, focusing on relieving the discomfort. Age could have either a positive or negative effect during crisis, depending on previous experiences. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Therefore, previous coping skills is the best answer. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis as well as a better solution to the problem. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome.
- B. Removing items that the client could use in a suicide attempt. The nurse’s first responsibility is to protect the client from injuring himself. Listening and being nonjudgmental are important elements of the nurse’s communication with the client. After the client’s safety has been established, he would benefit from a referral to a mental health professional.
- D. Excessive and ritualized exercise. A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible. The client will usually wear loose-fitting clothing to hide what she considers to be a fat body. Skin and nails become dry and brittle, and blood pressure and body temperature drop from excessive weight loss.
- B. The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.
- C. express feelings that he can’t articulate. Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. It’s important for the child to find a way to express internalized feelings. The child must also know that he isn’t to blame for this situation. In the process of doing play therapy, the child can also have fun, but that isn’t the main goal of therapy.
- A. Abstinence is the basis for successful treatment. The foundation of any treatment for alcoholism is abstinence. Attendance at AA is helpful to some individuals to maintain strict abstinence. Participation in treatment by the family is beneficial to both the client and the family but isn’t essential. Abstinence requires refraining from social drinking.
- D. Call for a multidisciplinary staff meeting. The nurse would call for a multidisciplinary staff meeting because there is a need for staff members to share their feelings of anger, frustration, and grief. Because nurses focus on saving human lives, any feelings of hopelessness regarding a dying client can interfere with the client’s care and management. Assigning the staff member to other clients ignores the staff’s need to work through feelings. Calling the clinical nurse specialist to deal with the staff member does nothing to help the immediate situation. The psychiatric clinical nurse specialist would be included in the staff meeting to help the entire staff deal with their feelings. Agreeing with the staff member and discontinuing suicide precautions is highly inappropriate.
- D. Verbalize the desire to stop drinking alcohol. Verbalizing the desire to stop drinking alcohol is an initial outcome that acknowledges alcohol consumption as a problem behavior and leads to further participation in treatment. Describing adaptive methods to use instead of drinking alcohol to induce sleep is an outcome to be reached later in the client’s course of treatment. Verbalizing the negative effects of alcohol on the body is a therapeutic behavior but is not specific to helping the client sleep. Describing the dangerous effects of using alcohol with antidepressant medication is a therapeutic behavior but is not specific to helping the client sleep.
- B. Drug classifications. Focusing on antidepressant medications would be helpful, but the topic of drug classifications is too general. A topic such as managing the depressed client at home will help family members learn positive techniques for managing day-to-day problems and will promote family cohesiveness. A topic such as receiving support from self-help groups is helpful to family members to reduce feelings of isolation and powerlessness. Educating the family about the illness dispels myths, enlists family cooperation, and promotes adaptive coping skills.
- A. Have the support of rehabilitated alcoholics. Membership in Alcoholics Anonymous is voluntary. Its rehabilitated members are available to support alcoholics, and the understanding and influence of these rehabilitated members often helps alcoholics change their behavior. The role of rehabilitated members does not include sympathizing with others abusing alcohol. The role of rehabilitated members does not include helping others abusing alcohol to identify personal problems. The role of rehabilitated members does not include helping others abusing alcohol to develop defense mechanisms to cope with alcoholism.
- D. “Tell me more about what you mean when you say you can’t make it without your wife.” The nurse helps the client explore his feelings by expressing interest in knowing more about his problem in order to make an accurate assessment. Cliches minimize the client’s feelings and block expression. Statements that make unwarranted judgments about the client block communication and may suggest that he should feel guilty for his feelings. The nurse has not explored the client’s feelings or made any assessment. Asking the doctor for sleeping pills reflects poor judgment based on insufficient assessment data. Sleeping pills may be inappropriate and not therapeutic for this client.
- B. “When it’s not too bad, the abuse adds spice to our relationship.” Violence is never acceptable to a victim; this myth condones the use of violence. Often, an episode of battering is followed by a period of pleasant relations between the partners, during which the victim may hope that the violence will never happen again. The victim may stay in the relationship for that reason.Women are conditioned to be responsible for the family’s well-being. This is often a motivation for a battered woman to stay in an abusive relationship. The victim believes that she can save the relationship and that her partner will change. Feelings of guilt surrounding issues such as these often influence an abused woman’s decisions about staying with her partner. A woman’s lack of job skills and financial resources may cause her to stay. Many women are injured or killed when they try to leave in a violent relationship.
- B. Consult with the physician about changing the medication to haloperidol decanoate (Haldol Decanoate) injections. For the client who is noncompliant with oral medication, depot medication is advantageous because the client will only need to keep one appointment every 2 to 4 weeks instead of taking medication daily. Education may or may not affect the client’s compliance with medication. Long-term commitment is unnecessary at this time. Participation in a partial hospitalization program may be a desirable referral but would only indirectly affect the client’s compliance with medication.
- B. Questions the physician about the order. The nurse questions the physician about the order because the client who has been taking an MAOI such as phenelzine must wait 14 days after stopping the MAOI before starting an SSRI such as paroxetine. Serotonin syndrome, a potentially lethal consequence, can occur when combining an MAOI and an SSRI. Serotonin syndrome is characterized by hyperreflexia, hyperthermia, myoclonus, and other symptoms similar to neuroleptic malignant syndrome. Giving the medication as ordered can result in serious adverse consequences, as described above. The dosage is accurate. Benztropine is not given with an SSRI; it is an antiparkinsonian agent usually ordered for the side effects of antipsychotic medication.
- C. Withhold the medication until it is determined why the client is refusing to take it. The client has a legal right to refuse treatment. When a client refuses medication, the nurse must explore the reason for the refusal. The desire to avoid unwanted side effects is a common reason. Legally a client cannot be forcibly medicated unless she is a danger to herself or others or there is a court order to treat. Legally a client cannot be forcibly medicated unless she is a danger to herself or others or there is a court order to treat. Lying to a client about a medication is neither appropriate nor ethical.
A. That the client should take Prozac in the morning. Fluoxetine should be taken as early in the day as possible so as not to interfere with nighttime sleep; it may cause nervousness in some clients. The dose is therapeutic and not too high. There is no evidence in this situation to justify the conclusion that the client’s depression is worsening. There is no evidence in this situation to justify the conclusion that the client is on the wrong medication.