question

Physical tolerance and withdrawal symptoms can occur with stimulants. Stimulant withdrawal is characterized by which symptoms?

answer

A violation of confidentiality because she informed the officer that the client wasn't there

question

Two nurses are discussing a client's condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which accusation?

answer

"Breach of confidentiality

question

(SELECT ALL THAT APPLY) A client is prescribed bupropion (Wellbutrin) to treat depression. The nurse should monitor the client for which adverse reactions associated with bupropion therapy?

answer

(1) Seizures, (2), Anxiety, (3) Insomnia

question

The basis for building a strong therapeutic nurse-client relationship begins with the nurse's:

answer

self-awareness and understanding.

question

A 21-year-old college student who has been staying up late at night to study reports that she's been having difficulty concentrating. Which response by the nurse is best?

answer

"Describe your sleep patterns to me."

question

Which of the following statements describes how elderly clients react to medications?

answer

At risk for increased adverse effects

question

Which task may be delegated to a nursing assistant in an acute mental health setting?

answer

Checking for sharp objects

question

Physical tolerance and withdrawal symptoms can occur with stimulants. Stimulant withdrawal is characterized by which symptoms?

answer

Fatigue, mental depression, and confusion

question

A client with antisocial personality disorder smokes where it's prohibited and refuses to follow other unit and facility rules. The client gets others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The plan of care for this client should focus primarily on:

answer

isolating the client to decrease contact with easily manipulated clients.

question

(SELECT ALL THAT APPLY) The nurse is teaching a client about the antidepressant amitriptyline (Elavil). Which points should she include in her teaching plan?

answer

(1) Smoking may lower the drug level., (2) Avoid prolonged exposure to the sun., (5) Increase fluid and fiber intake to prevent constipation.

question

An extremely manipulative client is evoking angry feelings in a nurse. Which action should the nurse take first?

answer

Confront the client about his manipulative behavior.

question

A man at a pizza parlor verbally confronts the waiter for lack of attentiveness. Later, in the back room, the waiter spits on the man's pizza. This is an example of a behavior typical of which disorder?

answer

Passive-aggressive

question

Which psychological or personality factor is likely to predispose an individual to medication abuse?

answer

Low self-esteem and unresolved rage

question

Conditions necessary for the development of a positive sense of self-esteem include:

answer

consistent limits.

question

In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which of the following roles is the client playing?

answer

Aggressor

question

The nurse is performing an assessment on a newly admitted client. She asks the client to remember three words: apple, house, and umbrella. Then she asks the client, "What are the three words I want you to remember?" What is the nurse assessing?

answer

Immediate recall

question

What is the nurse's most important role in caring for a client with a mental health disorder?

answer

To establish trust and rapport

question

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with the client?

answer

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"

question

Which term refers to the primary unconscious defense mechanism that keeps intense anxiety-producing situations out of a person's conscious awareness?

answer

Repression

question

The nurse enters the room of a client who is visibly shaken. The nurse states, "You seem upset." The client doesn't respond, so the nurse sits down with the client and remains silent. By using this therapeutic communication technique the nurse is exercising her knowledge that silence is:

answer

a means of allowing the client space in which to respond and a way of communicating patience.

question

(SELECT ALL THAT APPLY) The nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage?

answer

(1) The client addresses how the addiction has contributed to family distress., (4) The client discusses the financial problems related to the addiction., (6) The client acknowledges the addiction's effects on the children.

question

A person loses an important advertising account and has a flat tire while driving home. That evening, the person begins to find fault with everyone. Which defense mechanism is the person using?

answer

Displacement

question

A women seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self conscious. She also has aches and pains. A nursing diagnosis for this client might include:

answer

Situational low self-esteem.

question

A voluntary client in a facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following?

answer

False imprisonment

question

When should the nurse introduce information about the end of the nurse-client relationship?

answer

During the orientation phase

question

Which nursing intervention is initially most important when restraining a violent client?

answer

Ensuring that the restraints have been applied correctly

question

Which of the following statements accurately describes therapeutic communication?

answer

Avoiding judgment and false reassurance

question

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

answer

Tachycardia, weight loss, and mood swings

question

SELECT ALL THAT APPLY client suffering posttraumatic stress disorder is prescribed sertraline (Zoloft), 50 mg by mouth once daily. Which actions should the nurse take when administering this drug?

answer

(2) Mix the oral concentrate with 4 oz (120 ml) of water, ginger ale, or lemon-lime soda., (3) Administer the oral solution immediately after dilution., (4) Instruct the client to check with the prescriber or pharmacist before taking over-the-counter preparations., (5) Advise the client to use caution when performing hazardous tasks that require alertness.

question

The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's:

answer

affect.

question

The terms "judgment" and "insight" are sometimes used incorrectly. Insight is the ability to:

answer

understand the nature of one's problem or situation.

question

The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The primary purpose of these techniques is to help the child:

answer

express feelings that he can't articulate.

question

A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?

answer

Every 15 minutes

question

In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The appropriate response by the nurse would be:

answer

"Will you briefly summarize your point because others need time also?"

question

What occurs during the working phase of the nurse-client relationship?

answer

The nurse and client evaluate and modify the goals of the relationship.

question

Common adverse effects of electroconvulsive therapy (ECT) include:

answer

short-term memory loss.

question

An agitated client demands to see her chart so she can read what has been written about her. Which statement is the nurse's best response to the client?

answer

"You have the right to see your chart. Please discuss this with your primary care provider."

question

A nurse is assessing a psychiatric client's ability to make sound judgments. Which assessment request best helps evaluate the client's judgment?

answer

"What would you do if you smelled gas in your house?"

question

A client admitted to the facility continually acts out a preoccupation with hand washing. What term should the nurse use to document this behavior?

answer

Compulsion

question

(SELECT ALL THAT APPLY) The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion?

answer

(2) Right to refuse treatment, (4) Right to confidentiality, (5) Right to personal mail

question

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first?

answer

Observe how the client and his family and friends interact with each other and with other staff members.

question

Which statement is a guideline to help nurses effectively avoid liability?

answer

Practice within the scope of the Nurse Practice Act.

question

A recently engaged 22-year-old woman loses her fiancé in a drunken driving accident. She complains of difficulty eating, sleeping, and working. Her reaction is considered:

answer

a crisis caused by traumatic stress.

question

A client is taking clozapine (Clozaril) and complains of a sore throat. This symptom may be an indication of which adverse reaction?

answer

Agranulocytosis

question

Which of the following observations should a nurse identify as a group process when monitoring a group therapy session?

answer

Nonverbal language expressed within the group

question

On admission to the mental health unit, a client tells the nurse she's afraid to leave the house for fear of criticism. She informs the nurse "My nose is so big. I know everyone is looking at me and making fun of me. I had plastic surgery and it still looks awful!" These symptoms are an indication of which disorder?

answer

Body dysmorphic disorder

question

During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." The purpose is to evaluate the client's ability to think:

answer

abstractly.

question

Which commonly administered psychiatric medication is prescribed in individualized dosages according to the blood levels of the drug?

answer

Lithium carbonate (Lithane)

question

A client is admitted to a psychiatric unit in a state of emotional distress after his wife filed for divorce and he lost his job. Which assessment should take priority for this client?

answer

Identify the client's perception of the event.

question

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses?

answer

All behavior has meaning.

question

(SELECT ALL THAT APPLY) In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, ""How long do I have to stay here?""

answer

(1) "You may leave the hospital at any time unless you are suicidal.", (2) "Let's talk more after the health team has assessed you.", (4) "Because you could hurt yourself, you must be safe before being discharged."

question

A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which action?

answer

Consulting with the physician about a plan of care

question

The nurse is administering atropine sulfate to a client who is about to undergo electroconvulsive therapy (ECT). Which data collection finding indicates that the medication is effective?

answer

The client states that his mouth is dry.

question

A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which technique?

answer

Making observations

question

A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:

answer

remove all other clients from the day room.

question

Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate that restraints can be used:

answer

if the client poses a present danger to himself or others.

question

Nursing care for a client after electroconvulsive therapy (ECT) should include:

answer

assessment of short-term memory loss.

question

The nurse is documenting a plan of care for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention?

answer

Reorienting the client to time and place

question

According to Freud's psychosexual theory, the ego has several functions. The primary function of the ego is to:

answer

test reality and direct behavior.

question

An elderly client is prescribed fluoxetine (Prozac), 40 mg by mouth twice per day, for treatment of depression. The client has difficulty swallowing, so the pharmacy dispenses the oral solution containing 20 mg/5 ml. How many milliliters of solution should the nurse administer to achieve the prescribed dose?

answer

10

question

A client is brought to the facility in an agitated state and is admitted to the psychiatric unit for observation and treatment. While putting personal items away, the client talks rapidly and folds and unfolds garments several times. The client can't seem to settle down. Which nursing diagnosis is most applicable at this time?

answer

Anxiety

question

The nurse's goal in crisis intervention is to provide:

answer

problem-solving techniques and structured activities.

question

A family member visiting on an acute care psychiatric unit approaches the nurse's station and reports that an elderly client is walking in the hall without her clothing. The nurse doesn't assist the client and suggests that the family member inform the nurse assigned to that client. Which term describes the nurse's action?

answer

Negligent

question

A nurse immediately tells the truth about a medication error that she made. This nurse is following which ethical principle?

answer

Veracity

question

A client asks the nurse, "Do you think I should leave my husband?" The nurse responds, "You aren't sure if you should leave your husband?" The nurse is using which therapeutic technique?

answer

Reflecting

question

Erikson described the psychosocial tasks of the developing person in his theoretical model. He proposed that the primary developmental task of the young adult (ages 18 to 25) is:

answer

intimacy versus isolation.

question

A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique?

answer

Focusing

question

The nurse is caring for a client who continually has paranoid thoughts. How should the nurse interact with this client?

answer

Approach him in a nonthreatening way.

question

Which goal is most important for a nurse to concentrate on when leading a group session using a therapeutic milieu?

answer

Focusing on the here and now

question

A 22-year-old male client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he's anxious. Which of the following responses would be best?

answer

"Clients are permitted to smoke at designated times. You'll have to follow the rules."

question

Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of:

answer

abuse and neglect.

question

The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should:

answer

encourage verbalizations about fears and stressful life situations.

question

An 8-year-old girl and her 5-year-old sister tell the school nurse that their mother frequently yells and spits in their faces when she is mad at them. The nurse hesitates to intervene because she knows the family personally. Which action by the nurse is appropriate?

answer

Report the information to child protective services.

question

A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — the nurse the client is talking to at the time. This client is demonstrating which behavior?

answer

Splitting

question

The nurse collecting data on a client asks the client the meaning of the proverb "People in glass houses shouldn't throw stones." What is the nurse assessing by asking this question?

answer

Concept formation

question

Which of the following indications is the appropriate use for electroconvulsive therapy (ECT)?

answer

Major depression with psychotic features

question

The goal of crisis intervention is:

answer

psychological resolution of the immediate crisis.

question

A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which technique?

answer

Exploring

question

A client in an acute care center lacerates her wrists. She has a history of conflicts and acting out. The client tells the nurse, "I did a good job didn't I?" Which of the following responses would be appropriate?

answer

"What were you feeling before you hurt yourself?"

question

A client is transferred to the locked psychiatric unit from the emergency department after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. Now the client is awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

answer

ensure safety by initiating suicide precautions.

question

The charge nurse in an acute care setting assigns a client, who is on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered:

answer

reasonable nursing practice because one-to-one requires the total attention of a staff member.

question

Upon returning home from work, a young man discovers that his mother has been in a serious automobile accident. Initially, he responds to the news by stating, "No, I don't believe it. It can't be true." Which defense mechanism is he using?

answer

Denial

question

An adolescent, age 17, rarely expresses feelings and usually remains passive. However, when angry, her face becomes flushed and her blood pressure rises to 170/100 mm Hg. Her parents are passive and easygoing. The adolescent may be using which defense mechanism to handle anger?

answer

Introjection

question

A client reports severe pain in the back and joints. Upon reviewing the client's history, the nurse notes a diagnosis of depression and frequent hospitalizations for somatic illnesses. What should the nurse encourage this client to do?

answer

Tell the physician about the pain so that its cause can be determined.

question

Sedative-hypnotic drugs are indicated for:

answer

anxiety and insomnia.

question

An appropriate way for the nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the room designated for smoking is to:

answer

hand the client an ashtray and state that he must use it or he won't be allowed to smoke.

question

A client in the emergency department expresses suicidal ideation and feelings of worthlessness. He has a family history of suicide. The nurse is collecting data on the client. The most important factor to consider is:

answer

whether the client has an active suicide plan and the means to carry it out.

question

A client is admitted to an inpatient psychiatric unit. After data collection and admission procedures are completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in a specific corner of the dayroom." What is the main rationale for communicating these planned nursing interventions?

answer

To establish a trusting relationship

question

Assertive behavior involves which of the following elements?

answer

Standing up for your rights while respecting the rights of others

question

A community mental health nurse recognizes that one of the primary roles of her position is advocacy. Which action is most important when fulfilling an advocacy role?

answer

Being politically involved

question

During an initial assessment, a client reports the following behaviors: social inhibition, hypersensitivity to negative evaluation, fear of criticism, and social ineptitude. The nurse suspects which of the following personality disorders?

answer

Avoidant

question

Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of:

answer

poor boundaries.

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