Quiz 2

Question 0

An older adult on the mental health unit begins acting out while in the day room. What is the nurses initial intervention?

Answer 0

Give the client directions in affirm, low pitched voice

Question 1

A nurse is best approach when caring for a confused all their client is to provide an environment with….

Answer 1

Trusting relationships

Question 2

A nurse is assessing an older adult with the diagnosis of dementia. Which manifestations are expected in this client?

Answer 2

1. Resistance to change
2. Inability to recognize familiar objects
3. Inability to concentrate on new activities
4. Tendency to dwell on the past and ignore the present

Question 3

When answering questions from the family have a client with Alzheimer’s disease the nurse explains this disease is…

Answer 3

A slow and relentless deterioration of the mind

Question 4

A client in the early dementia stage of Alzheimer’s disease is admitted to a long-term care facility. Which activities must the nurse indicate…

Answer 4

1. Weigh the client once a week
2. Have specialized rehabilitation equipment available
3. Establish a schedule with periods of rest after activities

Question 5

Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care because these clients need to…..

Answer 5

Have sameness and consistency in their environment

Question 6

A nurse is assessing a client with dementia. Which clinical manifestations are expected?

Answer 6

1. Agitation
2. Short attention span
3. Disordered reasoning
4. Impaired motor activity

Question 7

What is the priority nursing objective of the therapeutic psychiatric environment for a confused client?

Answer 7

Maintain the highest level of safe, independent functioning

Question 8

What is the most appropriate nursing intervention for clients exhibit mild cognitive impairment?

Answer 8

Reality orientation

Question 9

What are the four A’s for which nurses should assess client suspected of having Alzheimer’s disease?

Answer 9

Amnesia, apraxia, agnosia, aphasia

Question 10

An older adult is brought to the clinic by family member because of increasing confusion over the past week. What can the nurse ask clients to assess their orientation to place?

Answer 10

Identify the name of the town

Question 11

A nurse is assigned to care for regressed college student who is been talking to unseen people and refusing to get out of bed, go to class, or get involved in daily grooming activities. What is the nurses initial effort toward helping the client?

Answer 11

Attempting to establish a meaningful relationship with the client

Question 12

A client diagnosed with schizophrenia is experiencing auditory hallucinations. Nurse makes the following statements when interacting with this client. Plessis statements in order in which they should occur

Answer 12

1. Hearing voices must be frightening
2. The voices you hear our part of your illness
3. I do not hear any voices
4. Come with me for a walk
5. Let’s play cards with another client in the recreation room

Question 13

A client with schizophrenia has a history of hearing voices that say you were a bad person. While having a conversation with the nurse with him the client has been working on the client said I’m sorry to hear the same voices again what is the nurses best response?

Answer 13

Try to ignore the voices

Question 14

What should the nurse do and caring for a client whose behavior is characterized by pathologic suspicion?

Answer 14

Help a client to feel excepted by the staff on the unit

Question 15

One evening a nurse find the client has been experiencing persecutory delusions trying to get out the door. The client states please let me go I trust you the mafias getting to kill me tonight. What responses most therapeutic?

Answer 15

You are frightened. Come with me to your room and we can talk about it

Question 16

I delusional client refuses to eat because of the belief that the food is poisoned. What is the most appropriate initial nursing intervention

Answer 16

States that the food is not poison

Question 17

The client was schizophrenia is admitted to an acute care psychiatric unit which clinical findings indicate positive signs and symptoms associated with schizophrenia?

Answer 17

Hyperactivity, auditory hallucinations, loose associations

Question 18

And acutely ill client with the diagnosis of schizophrenia has just been admitted to the mental health unit. What is the most therapeutic initial nursing intervention?

Answer 18

Spend time with the client to build trust and demonstrate acceptance

Question 19

A client with schizophrenia plans and activities scheduled with the help of the treatment team. A written copy is posted in the clients room. What should the nurse say when it is time for the client to go for a walk?

Answer 19

It’s time for you to go on a walk now

Question 20

During the admission procedure, client appears to be responding to voices. The client cries out at intervals, no no I didn’t kill him. You know the truth tell the police officer please tell me. What is the nurses most appropriate response?

Answer 20

Respond by saying I want to help you. I realize you must be very frightened

Question 21

A client is delusional, talking about people who are plotting to do harm. A nurse identifies with the client was pacing more than usual and is concerned that the client is beginning to lose control. What is the best nursing intervention?

Answer 21

Move the client to a quiet place on the unit

Question 22

A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicate the hearing the voices. When I nursed begins to walk toward the client the client pulls out a large knife. Which is the nurses best approach?

Answer 22

Firm

Question 23

While the nurse was talking with the client another client comes up and yells I hate you you’re talking about me again and throws a glass of juice at the nurse. What is the nurses best response to this outburst?

Answer 23

Remove the client from the room because limits must be placed on the behavior

Question 24

As a nurse enters the room and approaches the client my schizophrenia the client states get out of here before I hate you go away the nurse conclude that this aggressive behaviors probably related to the fact that the client felt…

Answer 24

Trapped when the nurse walked into the room

Question 25

A client experiences auditory hallucinations agrees to discuss alternative coping strategies with the nurse. For the next three days when the nurse attempts to focus on alternative strategies the client gets up and leaves interaction. What is the nurses most therapeutic response?

Answer 25

You seem very uncomfortable every time I bring up a new way to cope

Question 26

What is a nurse is most appropriate action want to climb a scene openly masturbating in the recreation room?

Answer 26

Escorting the client out of the room

Question 27

What’s of the nurse do to achieve a primary objective of providing therapeutic daycare environment for a client who is withdrawn and reclusive?

Answer 27

Foster a trusting relationship

Question 28

A client experiencing hallucinations tell the nurse the voices are telling me I’m no good. The client asked whether the nearest hears the voices. What is the nurse is most appropriate response?

Answer 28

No I do not hear the voices but I believe that you can hear them

Question 29

I nurse enters the clients room and identifies at the client appears preoccupied. Turning to the nurse the client states they’re saying terrible things about me can you hear them? What is the nurses most therapeutic response?

Answer 29

I don’t hear anyone else talking but I can see you’re upset

Question 30

The nurse observes a regressed emotionally disturbed client using the hands to eat soft food. What is the best nursing intervention?

Answer 30

Give the client a spoon and suggest it to be used

Question 31

What clinical manifestation is the most serious indication of impeding assaultive behavior by client on a mental health unit?

Answer 31

Experiencing command hallucinations

Question 32

While watching tv in the day room, client who is demonstrated withdrawn, regressed behavior send the screens burst into tears and runs out of the room to the far end of the hallway. What is the most therapeutic action by the nurse?

Answer 32

Walk to the end of the hallway where the client is standing

Question 33

How should the nurse intervene when I regressed emotionally disturbed client boys on the floor in the sitting room of the mental health unit?

Answer 33

Toilet the client more frequently with supervision

Question 34

I regressed emotionally disturbed client who’s been watching a nurse for a few days suddenly walks up and shout you think you’re so damn perfect and good I think you stink what is the nurse is most appropriate response?

Answer 34

You seem angry with me

Question 35

A client tells the nurse I am a terrible evil person the voices are telling me that God needs to punish me. What is the nurses most therapeutic intial response?

Answer 35

Tell me what you’re thinking about yourself

Question 36

What is the most appropriate way for the nurse to help at withdrawn emotionally disturbed adolescent client to except the realities of daily living?

Answer 36

Assist the client to care for personal hygiene needs

Question 37

What is the best nursing interventions to encourage a withdrawn noncommunicative client to talk?

Answer 37

Focus on nonthreatening subjects

Question 38

What is an important aspect of nursing care for client exhibiting psychotic patterns of thinking and behavior?

Answer 38

Help keep the client oriented to reality

Question 39

Why is observation an especially important aspect of nursing care for a withdrawn client?

Answer 39

That helps in understanding the clients behavior

Question 40

Client admitting history indicates signs of akathisia. What clinical findings should the nurse expect when assessing for akathisia?

Answer 40

Motor restlessness