question

While taking a health history from a client in the outpatient mental health clinic, nurse observes that the client is persistent in making personal inquiries. Which of the following is the most therapeutic response?

answer

Explain to the client that this time is for him Focus of relationship is on the client's ideas, experiences, and feelings.

question

A nurse is caring for a client diagnosed with dementia. She should understand that the goal of reminiscence therapy in long term care facilities is to....

answer

share memories of past experiences and events

question

Which of the following is an important short term goal for a nurse to plan with a suicidal client?

answer

sign a contract pledging not to act on suicide plans

question

A nurse's neighbor has just found out that her teenage child died in a motor vehicle accident. The neighbor is crying inconsolably. Which of the following is an appropriate therapeutic nursing response?

answer

Sit silently with the client while he cries. Being silent is a communication that is appropriate at times of grieving

question

A nurse is admitting an adolescent female to the psychiatric unit for observation related to clinical depression. After completing the admission assessment., the nurse should give greatest priority to which of the following finding?

answer

The client gave her favorite necklace to her best friend - sign of suicidal ideation

question

A parent brings an 18 month old child to the ER, the child sustained a fractured left femur. Which of the following statements by the parent might make the nurse suspect child abuse?

answer

My child was riding a bicycle and got the right foot caught in the spokes. Kid is TOO young and not developmentally capable of riding a bike

question

A nurse should assess that the client with the highest potential for suicide is the depressed client who states which of the following?

answer

I don't feel like going to group therapy today. I don't want to be with other people. - manifestation of severe depression

question

A nurse is caring for a client dx with disorganized schizophrenia. The client does not return a visitors greeting and instead lies down on the bed and curls up in the fetal position. Which of the following defense mechanisms is the client exhibiting?

answer

Regression - represents dysfunctional attempt to reduce anxiety and conflict by returning to less mature behaviors that help the client tolerate the anxiety

question

A client was admitted to the psychiatric unit with a dx of bippolar d/o. At 3a the client runs to the nurses station and demands to see the therapist immediately. Which of the following responses by the nurse is appropriate?

answer

You must be very upset about something to want to see your therapist in the middle of the night

question

A client is admitted to the psych unit following tx in the ER for an intentional OD ingestion. As the nurse performs the admission assessment, the client says Why would you want to waste your time on a worthless person like me? Appropriate therapeutic response?

answer

I think you are worthwhile, and I want to talk to you - offering one's self

question

The nurse should document that a client is experiencing mild anxiety when the nurse observes which of the following?

answer

The client is extremely alert. A heightened perceptual field and increased awareness.

question

A nurse is working in a busy pediatric ER. In which of the following cases should the nurse maintain a high index of suspicion of physical child abuse?

answer

A 9 month old who reportedly nearly drowned after climbing into the tub and turning on the water - inconsistent with developmental abilities

question

As a nurse approaches a client with schizophrenia, the client looks at the nurse and says Back off, leave me alone."The client appears tense and is pacing rapidly. Appropriate nursing response?

answer

I will you give you some space as long as you control yourself. I'd like to know what is causing you to feel so tense

question

A client who is bipolar states to the psych nurse in the mental health outreach clinic, I no longer take my meds because I like to feel manic.. Appropriate response?

answer

You feel better when you don't take your medication

question

The nurse in the oncology unit provides support to the parents of a child newly dx with a glioblastoma tumor of the brain. In planning care, the nurse understands the parents initial reaction to a potentially terminal illiness in their child is....

answer

denial and disbelief

question

A widow is brought to the clinic by her adult son, who found her at home crying. She said that she could not go on alone. He tells the nurse that when his father died six months earlier, and the family was amazed at his mother's fortitude during and immediately after the funeral. She did not cry or seem unduly upset. The nurse recognizes that his mother had previously dealt with her husbands death by using which defense mechanism?

answer

Denial

question

A nurse is caring for a client who is scheduled for a cardiac catheterization. When arriving for the procedure, the nurse reports waking that morning with butterflies in the stomach, a sense of restlessness, urinary frequency, and some difficulty concentrating while driving to the hospital. The admitting nurse should assess the client's anxiety level as which of the following?

answer

Moderate - combination of physical s/s and difficulty concentrating

question

The nurse asks a client who is suicidal to make a safety contract. The client states to the nurse I cannot make a safety contract, because I can't promise that I will not harm myself. Nurse's plan of care, initial action to ensure client safety?

answer

Have a staff member stay with the client at all times.

question

A client is admitted to the detoxification center for AA. On the day after admission, the client develops hand tremors, and asks the nurse about them. Appropriate nurse response?

answer

They will persist for a few days, now that you are not drinking

question

A client with dementia says to the nurse Everyone wants to kill me. Appropriate nursing response?

answer

You are frightened. This is a hospital and we are here to help.

question

A client dx with borderline personality d/o, has become attached to one of the nurses who calls in sick one day. When given the news the client breaks a glass bottle, and uses it to self-inflict a deep scratch. After providing first aid, therapeutic nursing response to client behavior?

answer

Help the client verbalize her feelings and reasons for the acting out behavior

question

A nurse is caring for a client admitted for depression 1 week ago who was started on paroxetine (Paxil) at the time of admission. The client states to the nurse, my family would be better off without me. appropriate nurse response?

answer

You sound upset, Are you thinking of hurting yourself?

question

A nurse is caring for a client whose provider has prescribed fluphenazine decanoate (Prolixin) 12.5mg IM weekly. Available is 50mg/2mL, How many mL each week?

answer

12.5 x 2 = 25 25 / 50 = 0.5 weekly

question

A client is admitted to the hospital with abdominal pain and GI bleeding has a colonoscopy, and colon cancer is discovered. The provider comes to the clients room, tells the client the dx, discusses tx options and leaves. Shortly after the nurse enters the room and the client begins yelling at the nurse stating I have recieved lousy care here and no ones cares about me. The nurse recognizes that the client is demonstrating the defense mechanism....

answer

displacement - redirecting of thoughts, feelings, and impulses from an object that gives rise to anxiety to a safer more acceptable one.

question

A nurse is caring for a client dx with borderline personality d/o. The client becomes attached to one of the nurses and refuses to talk with any other staff members. The client says the other staff members are abusive and untrustworthy. The client is using which defense mechanism?

answer

splitting - relating to others as if are all good or all bad

question

A client has been dx with anorexia nervosa. The nurse would anticipate that this client will display which off the following?

answer

A poor sense of self-identity - self image

question

A client is dx with schizophrenia says to the nurse, They lied about me and are trying to poison my food. Therapeutic response?

answer

You're having very frightening thoughts - common delusion

question

A nurse on a mental health care unit is providing care for a client dx with schizophrenia. The client is experiencing delusional thinking. Which of the following defense mechanisms is the client using when making delusional statements?

answer

projection - attributes unacceptable emotions and qualities to others.

question

A college junior comes to the campus health service with reports of severe epigastric distress, the nurse discovers the client has suffered from severe bulimia since freshman year. The client tells the nurse I know my eating binges and vomiting are not normal, but i cannot control it. Appropriate response ?

answer

You are feeling helpless about changing this behavior?

question

A nurse receives a call on a crisis intervention hotline from a client who threatens to commit suicide. Which would be the most important question for the nurse to ask?

answer

How will you carry out your plan?

question

While working with a client, a nurse unconsciously attributes negative feelings to the client and becomes antagonistic toward her. The nurse is demonstrating which of the following?

answer

Countertransference

question

A female client is seen in the ER with ecchymosis of the trunk and face. Upon direct questioning by the nurse, the client admits to having been struck by her spouse. When offered information about shelters for battered women, the client declines stating, I could never leave my husband because of my kids. Which of the following is an appropriate response?

answer

I am concerned about your safety

question

The spouse of a chronic alcoholic client says to the nurse, I told my husband I would leave if he did not get into tx. Now that he is here, I feel differently, What can I do to help him? Therapeutic response?

answer

Tell me more about the kind of help you feel you are able to provide at this time.

question

A nurse is caring for a college student at the campus mental health counseling center. The student comes to see the nurse after getting a low grade in a course, and spends the entire session blaming the teacher and complaining about the lack of help seminars. The nurse recognizes this behavior as an example of which of the following defense mechanisms?

answer

displacement - takes unacceptable emotions, ideas, or wishes and transfers them from their original object to a more acceptable substitute

question

A client in a long term care facility asks the nurse to telephone her husband and ask him if he remembered to pick up his suit at the cleaners. The nurse knows the client's husband died 5 years before. Appropriate response?

answer

You miss your husband a lot, don't you?

question

A nurse should recognize that magnetic resonance imaging MRI procedures are generally C/I for clients who have a fear of......?

answer

closed spaces - claustrophobia

question

A client is hospitalized with schizophrenia, During a conversation with a nurse, the client seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Appropriate response at this time.

answer

what were we discussing when you began to feel uncomfortable - open ended questions, encourage further communication and expression of feelings

question

A client w/ hallucinations is admitted to the psych unit. In the initial phase of establishing a therapeutic nurse client relationship, it would be appropriate for the nurse to explore which?

answer

perception of the presenting problem - reason for therapy

question

A client is admitted to the psych unit for depression. The nurse observes an improvement in the client's grooming when the client comes to breakfast freshly bathed wearing clean clothes and with combed hair. Appropriate response?

answer

You look nice after your bath and shampoo - acknowledge and affirm client behavior - provides positive reinforcement and is good for client's self-esteem

question

The nurse working with a depressed client notes that the client has not come to breakfast and finds the client still in bed in a nightshirt. The client tells the nurse I'm too sick to bother, leave me alone and go help someone else who is worth your time. Appropriate response?

answer

You sound very discouraged and hopeless today

question

A nurse is planning care for a client who has thoughts of suicide. Goals for nurse in plan of care?

answer

The client agrees to notify a staff member of thoughts of self-harm

question

A nurse enters a client room and observes the client is agitated and pacing rapidly. The client looks at the nurse and says Back off leave me alone, statement nurse should make?

answer

I will give space if you calm down, tell me what is causing you to feel so tense

question

A nurse is assessing a client who has anorexia nervosa. expeect the client to display which characteristics?

answer

possess feelings of decreased self worth

question

A nurse is assessing a client who is experiencing moderate level anxiety. Which of the following findings should the nurse expect?

answer

difficulty concentrating

question

A nurse in the ED is caring for female pt who has ecchymosis of the trunk and face, client reports her partner hit her, causing the injuries. when offered info about shelters for IPV the client declines stating, I could never leave my husband because of my kids" Appropriate response?

answer

The next time is occurs what might you do to ensure your safety?

question

A nurse is performing a mental health status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the clients remote memory?

answer

what year did you graduate from high school

question

A nurse is caring for a client who has dementia. The client states to the nurse. Everyone wants to kill me. Appropriate response?

answer

You must feel very frightened to think someone wants to hurt you.

question

A nurse is caring for a client whose adolescent child died in a motor vehicle accident. the client is crying inconsolably. Appropriate response?

answer

Stay with client and allow client to cry

question

A nurse is completing an admission assessment for an adolescent client who has depression. The nurse should ID which of the following findings as priority?

answer

The client gave his favorite possessions to friends

question

A nurse is conducting a counseling session with a client who has substance use d/o. The client repeatedly asks personal questions about the nurse. Which of the following actions should the nurse take?

answer

Explain this time is designated to focus on the client

question

A nurse receives a call on a crisis intervention hotline from a client.. Which of the following statements should the nurse ID as an overt statement indicating the clients risk for suicide

answer

There is no point in living any longer

question

A nurse is caring for a client who has depression and started taking paroxetine one week ago. The client states to the nurse My family would be better off without me. Appropriate response?

answer

You sound upset, are you thinking of hurting yourself

question

A nurse in a mental health facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by the new RN indicates understanding of the information?

answer

I should keep information private even after the client dies

question

A nurse is caring for a client at a college mental health counseling center. The client received a failing grade in a course and spends the entire counseling session blaming the teacher. The nurse should recognize this behavior as an example of which defense mechanism?

answer

Projection

question

A nurse in an ED is caring for an 18 month old toddler who has a fractured left femur. Which of the following statements by the toddlers parent should cause the nurse to suspect child abuse?

answer

My child was riding a bike and fell off

question

A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yells at her son stating quit lying about your father. the nurse should recognize that the client is demonstrating which of the defense mechanisms?

answer

denial

question

A nurse is caring for a client who has schizophrenia. the client states my internal organs have turned to stone. The nurse should document this findings as which type of delusion?

answer

somatic

question

A nurse is caring for a client who has alcohol use d/o and receiving tx for alcohol w/d. The client reports hand tremors, 12 hr after admission. Which of the following statements should the nurse make?

answer

The tremors will persist for a few days as you are w/d from alcohol

question

A nurse is caring for a client who has a major depressive d/o and recently started taking an anti-depressant. Nurse should ID which of the following client statements as priority?

answer

I have it all figured out. Everything is going to be okay now

question

A nurse is planning reminiscence therapy for an older adult client. The nurse should ID which of the following goals for client therapy?

answer

Client will gain increased self-esteem

question

A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which of the following actions should the nurse take during the orientation phase?

answer

ID the clients perception of the reason for therapy

question

a nurse is caring for a client who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings towards the client. The nurse should recognize that she is demonstrating which of the following behaviors?

answer

countertransference

question

A nurse is counseling a client who seems relaxed initially but then becomes restless and begins wringing his hands. The nurse states that the client seems tense. the client agrees. which of the following statements should the nurse make?

answer

what were we discussing when you began to feel uncomfortable?

question

A nurse in a pediatric ED is caring for four clients, the nurse should suspect possible abuse with which of the following clients?

answer

A 9month old infant who reportedly nearly drowned after climbing into the tub and turning on the water.

question

A nurse is preparing to admin fluphenazine decanoate 12.5 mg subQ. Available is 25mg/mL. How many mL?

answer

0.5

question

A nurse is caring for a client who has depression. The nurse observes the client has not come to breakfast and is still in bed. I am not worth your time, leave me alone and go help someone else. Appropriate response?

answer

In other words you seem to be saying you feel unworthy of help

question

A nurse is caring for a client who attempted suicide and refuses to sign a no-suicide contract. Which of the following actions should the nurse take when implementing suicide precaution?

answer

Place the client on one-to-one observation

question

A community mental health nurse is planning strategies to address substance use by adolescents. Which of the following interventions should the nurse plan as a method of primary prevention?

answer

provide a presentation at area high school on resisting peer pressure for substance abuse

question

A nurse is admitting a client following care in the ER for an intentional O/D of opioids. The client states I feel so alone, no one can help me. Appropriate response?

answer

I would like to sit and talk with you

question

A nurse at an acute mental health facility for a client who has acute mania due to bipolar d/o. At 0300 the client runs to the nurses station and demands to see the provider immediately. Therapeutic response?

answer

You must be very upset about something to want to see your provider in the middle of the night

question

A nurse is caring for a client who has borderline personality d/o. The nurse enters the clients room and finds the client cutting his flesh with a paper clip. After providing first aid. Which of the following actions should the nurse take FIRST?

answer

ID the client's feelings that led to self injurious behavior

question

A nurse is caring for a client who has borderline personality d/o. The client previous ID another nurse as his fav stating hes the best nurse ever. when the nurse calls in sick. which of the following indicates that the client is using splitting as a method of coping.

answer

He's the worst nurse that has ever taken care of me -relates that their all good or all bad

question

A nurse is providing support for the parents of a child who has a new dx of a terminal brain tumor. The nurse should expect the parents to experience which of the following of grief FIRST?

answer

denial

question

A nurse in a mental health clinic is caring for a client who has bipolar d/o and states I no longer take my medication because I like the feeling of being manic. Therapeutic communication?

answer

you feel better when you don't take your med?

question

A nurse is caring for a school-age client who begins wetting the bed after finding out that her parents are getting a divorce. The nurse should ID that the client is exhibiting which of the defense mechanisms?

answer

regression

question

a nurse at a college campus health clinic is caring for a client who reports manifest of bulimia nervosa, the client tells the nurse I know my eating binges and vomiting are not normal, but i cannot control it. appropriate response?

answer

your feeling helpless about changing this behavior

question

A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following should the nurse plan to take?

answer

Document the client's behavior q15 mins while restraints are in place

question

A nurse is caring for a client who has a new dx of colon cancer. Shortly after the client receives the dx the nurse enters the client's room and the client begins yelling. I have received terrible care here and no one cares about me. The nurse should recognize that the client is demonstrating which of the following defense mechanisms?

answer

displacement

question

A nurse is admin an oral sedative to a client who is receiving care following an involuntary admission. The client states i'm not taking any more medication. Which of the following actions should the nurse take?

answer

Document the client's refusal of the medication in the medical record - client's right to refused medication, EVEN IF tx is involuntary

question

A nurse in a mental health clinic is caring for a client who states I think i might have a problem with alcohol. Nurse action FIRST?

answer

Ask the client the complete a CAGE questionnaire Determines the impact of alcohol use in the clients life.

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