Review Questions Flashcards
1
Q
A nurse is caring for a client on acute mental health unit. The client reports hearing voices that are telling her to “kill your doctor.” Which of the following actions should the nurse take first?
A
Initiative one-to-one observation of the client.
2
Q
A nurse in a psychiatric unit is admitting a client who attacked a neighbor The nurse should know that the dient can be kept in the hospital after the 72-hr hold is over for wh of the following conditions?
A
The client is a danger to herself or others
3
Q
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short staffed and the client frequently fights with other clients. The nurses actions are an example of which of the following torts?
A
Faise imprisonment
4
Q
A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
A
An adult dient following a suicide attempt
5
Q
Which nursing objective would be essential in the therapeutic psychiatric environment for a confused cleint?
A
Maintaining the highest level of safe, independent function
6
Q
A registered nurse is educating a nursing student about community health nursing. Which point made by the student nurse needs correction?
A
Community health psychiatric nursing does not provide direct or indirect care services to subpopulations in a community
7
Q
The nurse is caring for a group of clients in the psychiatric unit. Which clinical findings will alert the nurse that serotonin syndrome has developed in one of the clients? (Multiple Response)
A
Restlessness, tachycardia, fever, diarrhea, and altered mental status
8
Q
A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?
A
1 understand that you are angry. However, I followed the appropriate protocol.”
9
Q
A nurse hears a newly licensed nurse discussing a client’s hallucinations in the hallway with another nurs Which of the following actions should the nurse take first?
A
Tell the nurse to stop discussing the behavior
10
Q
A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication?
A
Intonation
Intonation is the tone of one’s voice and can communicate a variety of feelings.
Nurses can communicate feelings (acceptance, judgment, dislike) through tone of voice.
11
Q
A client with profoundly depressed behavior is undergoing a pretreatment evaluation for electroconvulsive therapy (ECT), but the nurse is unsure if the client can provide informed consent. Which intervention would the nurse use first?
A
Ask the client to verbalize an understanding of the outcomes of the procedure
12
Q
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
A
Secure the restraints using a quick-release tie. Secure the restraints using a quick-release tie.
13
Q
A newly admitted shy, withdrawn adolescent boy asks an experienced female psychiatric nurse for initial response will the nurse use?
A
Restate the purpose of the nurse-client relationship
14
Q
Which information is accurate regarding the role of value clarification in the resolution of psychiatric ethical dilemmas?
A
Tolerating differences of opinion
15
Q
The psychiatric nurse on the in-patient detox unit adheres to which principle when withholding a prescribed opioid medication from the client requesting to be treated for fear that the client is abusing the medication.
A
Paternalism
16
Q
A client with a mental illness in the emergency unit needs to undergo emergency surgery. Which would be the nurse’s first course of action to prevent any legal complications?
A
Obtain consent from a person legally authorized to give it on the client’s behalf, it available
17
Q
A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: “Everyone think you should be able to put it out of your mind. It happened so long ago - just get over it!” The nurse responds must be very frustrating to encounter this kind of attitude.” The nurse is using which of the following therapeu communication techniques?
A
Reflection
18
Q
A nurse is caring for a client who has a mental health disorder. The client asks about his medications and their effects. The nurse asks the client why he needs to know this. Which of the following nontherapeutic communication techniques is the nurse using?
A
Asking for explanation
19
Q
Which characteristic would be the most helpful for an individual client to gain therapeutic benefits from group therapy?
A
Ability to recognize own problems
20
Q
A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?
A
“Clients who are involuntarily admitted have the right to informed consent.”
21
Q
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse’s station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
A
“You must be very upset about something.”
22
Q
A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intevention?
A
Preparing for artificial ventilation
23
Q
A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)
A
Gender
Perception
Education
24
Q
Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication?
A
Offering advice
25
A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
Set behavioral limits for the client.
26
Which statement would the nurse make to a newly admitted, depressed, tearful client who looks intently at the nurse but says nothing when the nurse offers to walk with the client to the lunch table?
It must be very difficult for you to be on a psychiatric unit
27
A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit?
The client follows directions.
28
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (select all that apply.)
b. "client was offered 8 oz of water every hr."
CORRECT: how much water was offered and how often it was offered is objective data that the nurse should document
c. "client shouted obscenities at assistive personnel."
CORRECT: a description of the client's verbal communication is objective data that the nurse should document
d. "client received chlorpromazine 15 mg by mouth at 1000."
CORRECT: the dosage and time of medication administration is objective data that the nurse should document
29
Which scenarios relate to the psychiatric nurse's commitment to ethics and fidelity in practice? (Select all that Apply)
"A nurse monitors a client after providing nonpharmacological measures to relieve anxiety due to hospitalization."
"A nurse notes that the pain relief measures provided to that client have been ineffective. The nurse formulates a different plan of care."
"A nurse is caring for a client who refuses to be touched by people of certain skin color. The nurse continues providing care since other colleagues refuse to attend to the client."
30
A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?
Another staff nurse provides testimony about how reasonable, prudent nurses would have handled the situation
Response Feedback:
The definition of negligence is practice that is below the standard of care. The benchmark for standard of care is what a reasonable, prudent person who has similar background and experience would do. Another staff nurse who has similar background is the correct person to provide testimony.
31
Which steps listed by the nursing student are accurate regarding discharge planning for psychiatric patients? Select all that apply. One, some, or all responses may be correct.
Remember that discharge planning is a centralized, coordinated, interdisciplinary process
Teach the client the safe and effective use of medications and medical equipment '
Develop a care plan that moves the client from the hospital to another level of health care
32
When a client and the family are informed about electroconvulsive therapy (ECT) as a treatment option, the family urges the client to agree. Which ethical principle is involved in this decision-making?
Autonomy
33
Which statement is true of the relationship between bipolar disorder and suicide?
Suicide is a serious risk for nealry 20% of those diagnosed with bipolar disorder commint suicide
34
Which factor would be discussed when nurse educating a patient about bulimia nervosa is correct? (Select all that Apply)
Mnemonic REM
Relaxation Techniques
Effects of poging
Meal Planning
35
Which consideration must the nurse make before lithium can be started when planning care for a patio twho has mania.
The physical examination and laboratory tests are analyzed
36
Which classic characteristic is common among patients diagnosed with bulimia nervosa?
Onset in late adolescence
37
Which intervention would be included in the plan of care for a patient who takes lithium?
Conducting periodic laboratory monitoring of renal and thyroid function
38
Which action would the nurse take for a patient taking lithium carbonate who repeatedly requests water to drink and has slurred speech?
Evaluate the patient’s blood lithium level
39
Which clinical manifestation is identified as a symptom of anorexia nervosa ( Select all that apply)
Emaciation
Dehydration
Yellow Skin
40
Which sign or symptoms would the nurse expect a patient with a diagnosis of binge-eating disorder to exhibit
Obesity (also purging)
41
Which nursing action is appropriate when caring for a patient diagnosed with bulimia nervosa?
Monitor the patient’s bathroom trips after meals
42
Which statement regarding therapy with lithium is true? (Select All that apply)
It demonstrates effectiveness in the treatment of bipolar 1
Manic behavior generally show improvement in 10 to 21 days
Indeterminate maintenance dosing is required for many patients
43
Which assessment will the nurse perform on a patient suspected of having bulimia
Inspection of the oral cavity
44
A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa?
I have lost 60 pounds but I am still a size 1, want to be a size 0
45
Which complaint would receive the nurse’s priority attention when a patient who is diagnosed with bipolar taking lithium calls the nurse with multiple complaints?
I’ve had bad diarrhea for 3 days
46
Which symptom is most commonly seen in clients diagnosed with bipolar II disorder and experiencing hypomania?
Hyperactivity and high energy
47
Which laboratory values would be assessed for, in a patient taking lithium?
Sodium level
48
The nurse is managing the care of an older adult diagnosed with bipolar disorder who is in a manic phase. The nurse closely monitors the client for risks to safety. Which factor most indicates this intervention for this client?
Mania can result in irresponsible and physically risky behaviors
49
A nurse is caring for a client who has bipolar disorder. Which of the following is the proirity nursing action?
Monitor the client for escalating behavior
50
Which patient responses is indicative of suicidal ideation?
I fell like sleeping forever and never waking up again
51
A patient with bipolar disorder takes lithium. After playing soccer on a hot summer day, the patient complains of nausea, vomiting, diarrhea, and thirst. The patient's hands begin to tremble and the gait becomes unsteady. What is the priority nursing intervention? Select all that apply.
Instruct the patient not to take any more lithium until directed by the health care provider
Collaborate with the health care provider about drawing a serum lithium level immediately
52
A nurse is caring for a client who has bipolar disorder. The client states “ I am very rich and feel I must give my money to you. Which of the following responses should the nurse make?
I am here to provide care and cannot accept this from you
53
Which finding would cause the nurse to hold a dose of lithium for a patient with bipolar disorder?
Coarse hand tremors
54
A patient diagnosed with bipolar disorder and which additional acondition canbe safely prescribed lithium therapy
Erectile dysfunction
55
Which comment by a patient diagnosed with bipolar disorder indicates the patient is experiencing mania?
Yesterday I made 487 posts on my social network page
56
Which assessment question would the nurse ask a patient who has a suspected diagnosis of anorexia
How would you describe your body
57
Which condition is an advanced but not severe sign of lithium toxicity
Mental confusion
58
Which patient would be a candidate for ECT?
Has tried five different antidepressants with poor response
59
Which goals are appropriate for all patients diagnosed with an eating disorder? (Select all that Apply)
Restore nutritional state
Modify disordered eating behavior
Help change distorted beliefs about body image
60
A patient diagnosed with bulimia nervosa frequently uses enamas and laxatives to purge. Which imbalance might be present with this patient?
Disruption of fluid and electrolyte balance
Disruption of the fluid and electrolyte balance is usually the result of excessive use of enemas and laxatives. There would be a decrease in potassium and sodium levels while the concentration of but not actual red cell count would be affected.
61
Which finding reflects appropriate information to include when documenting the assessment and care provided in the record of patient admitted with bipolar disorder?
Patient states, “I do not want to talk about it”
62
Which instruction would the nurse include on the diet chart for a patient who has mania
Take lithium with meals
63
Which intervention would the nurse make for a patient diagnosed with bipolar disorder who has been receiving lithium for 15 days and is assessed to have increased restlessness, pressured speech and flight of ideas?
Consider the need to obtain a lithium level from the laboratory. The patient may not be swallowing the medication
64
A nurse is caring for a client who is hearing voices and is stating “kill the doctor.” Which of the following should the nurse do first?
Initiate one to one observation of the client
65
Which type of mental health disorder is most likely to include an assessment for presence of secondary gain?
Somatic Symptom Disorder
66
Which approach would the nurse use for a client with an OCD to decrease the use of ritualistic behavior?
Attempting to limit situations that will worsen the anxiety
67
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.)
obsessive thoughts about disease
History of childhood abuse
avoidance of health care providers
depressive disorder
68
A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. the nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?
Attempt to reduce anxiety.
Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety.
69
A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.)
Compulsions relieve anxiety. Correct
Anxiety is the key reason for OCD. Correct
Obsessive thoughts are linked to levels of neurochemicals. Correct
Antidepressant medications increase serotonin levels. Correct
70
Which actions would the nurse take to help a client with OCD discuss how anxiety influences feelings and the ability to function? (Select all that Apply)
Explore anxiety provoking situations
Assist the client in examining coping mechanisms
71
Which action would the nurse encourage a client with OCD who has red, raw, slightly bleeding hands from washing them 70 to 80 times a day to do?
Limit the number of times hand washing occurs
72
Which intervention would the nurse include in the intial plan of care for a client with the long standing OCD behavior of hand washing?
Develop a routine schedule of activities
73
A patient has been taking sertraline for the treatment. The patient reports insomnia. TO help provide relief from this side effect, when should the patient take this mediation?
In the morning
74
Most people can’t help the fact that they hoard because it is a behavior that is what
Compulsive
75
Sertraline can be prescribed first to reduce the symptoms of a female client who has severe cramping pain, backache, migraine headache and presents with anxiety and mood swings.
True
A client with severe cramps, backache, and a migraine with anxiety and mood swings likely has premenstrual syndrome (PMS). Selective serotonin reuptake inhibitors (SSRIs) such as sertraline are effective in relieving the symptoms of severe PMS.
76
A nurse in an acute mental health facility is planning care for a client who has obsessive- compulsive disorder (OCD). Which of the following actions should the nurse include in the plan?
Instruct the client to practice thought stopping.
Rationale: The nurse should teach the client who has OCD to use thought stopping. By saying "stop" out loud, the client can learn to interrupt obsessive thoughts.
77
A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement?
Report the client’s serum lithium level to the HCP.
78
A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take?
Prior to giving the next dose, notify the physician of the symptoms.
79
The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
Nausea and vomiting.
80
Lithium level 1.5. What do you tell the client who had a recent suicide attempt after seeing him become very anxious after hearing his Lithium levels?
drink 2-3L of water in 24 hours
81
A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assessment findings with the healthcare provider, a serum creatinine is obtained. What information supports the reason for this laboratory test
Lithium is excreted by the kidneys and creatinine is related to functioning
82
A young adult male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating from high school next month, and he tells the school nurse that wants to live away from home for college. What information is most important for the nurse to provide the client and his family?
Lithium level routinely.
83
What are the side effects of Lithium?
Dehydration, diarrhea, and thirstiness.
84
When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction?
Keep your dietary salt intake consistent.
Lithium's effectiveness is influenced by salt intake (B). Too much salt causes more lithium to be excreted, thereby decreasing the effectiveness of the drug. Too little salt causes less lithium tobe retained, potentially resulting in toxicity. (A, C, and D) are not specific instructions pertinent to teaching about lithium carbonate (Lithonate).
85
A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take?
Administer the next does of lithium
86
A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity?
A) A client who has a fasting blood glucose of 80 mg/dL
B) A client who has a sodium level of 128 mEq/L
C) A client who has a BUN of 18 mg/dL
D) A client who has potassium level of 3.6 mEq/L
Answer: B - A sodium level of 128 mEq/L should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level.
87
A nurse is teaching a client who has bipolar disorder about a new prescription for lithium carbonate. Which of the following statements by the client indicates an understanding of the teaching?
“I will call my doctor if I have diarrhea”
88
A client who has bipolar disorder to be discharged home with a prescription for lithium.Which of the following statements indicates that client teaching regarding the medication has been effective?
"I should eat a regular diet with normal amounts of salt and fluids."
This statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity.
89
A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that she stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?
A) Sore throat
B) Photophobia
C) Hand tremors
D) Constipation
Answer: C - Fine hand tremors are an expected adverse effect of lithium and can interfere with the client's ADLs, causing the client to stop taking the medication.
90
A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make?
“That is a good choice. Ibuprofen does not interact with lithium.”
“Regular aspirin would be a better choice than ibuprofen.”
“Lithium decreases the effectiveness of ibuprofen.”
“The ibuprofen will make your lithium level fall too low.”
“Regular aspirin would be a better choice than ibuprofen.”
91
A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (Select all that apply.)
Polyuria.
Muscle weakness.
92
A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client’s adult daughter, which of the following statements is the priority to report to the provider?
“My mother has diabetes that is controlled by her diet.”
“My mother recently completed a course of prednisone for acute bronchitis.”
“My mother received her flu vaccine last month.”
“My mother is currently on furosemide for her congestive heart failure.”
“My mother is currently on furosemide for her congestive heart failure.”
93
A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching?
-"Take this medication with food."
Lithium can cause gastrointestinal distress. Therefore, this medication should be taken with foo
94
Fine hand tremors are an expected adverse effect of _________ and can interfere with the client's ADLs, causing the client to stop taking the medication.
Lithium
95
Extreme distractibility is a hallmark manifestation of _______.
delirium
96
A sodium level of 128 mEq/Lshould alert the nurse that the client is at risk for ___________
because renal excretion of lithium is decreased in the presence of a low sodium level.
lithium toxicity
97
Lithium can cause gastrointestinal distress. Therefore, this medication should be taken ___________.
with food.
98
A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement?
Escort the client to a quieter place.
99
In the mental health field, hoarding is considered a tya symptom of what ?
An anxiety disorder
100
The nurse conducts a patient teaching on th side effects of Sertraine. Which side effect would the nurse teach the patient?
Being unable to sleep
101
For a client with OCD which event will increase the client’s anxiety level?
Limits are set on the performance of a ritual
102
Which client response would the nurse anticipate when an attempt is made to prevent an OCD client from carrying out a ritualistic behavior?
Anger
103
A nurse is developing a behavioral contract with the client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?
Decrease the number of verbal outbursts
104
A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder. Which of the following outcomes should the nurse include in the care plan?
The client recognizes the importance of others
105
A nurse is evaluating a care plan for a client who has an Antisocial Personality Disorder.
Which of the following client actions indicates he is making progress in treatments? (Select All That Apply)
Assisting another client who has depression to fill out a menu.
Requesting a weekend pass to go home.
Clients who have antisocial personality disorder tend to lack empathy for others and often display an inability to connect with others. Assisting another client indicates the client’s willingness to help and connect with others and demonstrates to the nurse his progress with treatment.
Clients who have antisocial personality disorder tend to disregard rules and have a lack of respect for authority. Requesting a weekend pass indicates the client’s willingness to follow unit rules and demonstrates to the nurse his progress with the treatment
106
A nurse is admitting a client who has antisocial personality disorder to an acute care unit.
The client is admitted under court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to display?
Anger with the nursing staff for hospitalizing him against his will.
A client who has antisocial personality disorder exhibits a low frustration level and can quickly become angry and aggressive when the situation goes against his will or desires
107
A nurse is assessing a client who has antisocial personality disorder. Which of the following client behaviors should the nurse expect?
Manipulative
108
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply)
Attempts to convince other clients to give him their belongings
Blames others for his past and current problems
109
School age children who have conduct disorder, choldhood onset type are at high rsk for progression gto which disorder during adolescense?
Antisocial Personality
110
Which statement by the client would alert the nurse the client is experiencing a somatic delusion?
My stomach has disintegrated
111
A client who is 16 years old, 5 foot, 3 inches tall, and weighs 80 pounds eats one tiny meal daily and engages in a rigorous exercise program. Which nursing diagnosis addresses this assessment data?
Imbalanced nutrition: less than body requirements
A body weight of 80 pounds for a 16-year-old who is 5 foot, 3 inches tall is ample evidence of this diagnosis. There is no support in the data as presented to justify any of the other nursing diagnoses
112
Which subjective symptom should the nurse would expect to note during assessment of a client diagnosed with anorexia nervosa?
Fear of gaining weight
Fear of weight gain is the only subjective data listed, and it is universally true of clients diagnosed with anorexia nervosa
113
The client experiencing bulimia differs from the client diagnosed with anorexia nervosa by exhibiting which characteristic?
Maintaining a normal weight
Many bulimics are at or near normal weight, whereas clients with anorexia nervosa are underweight. The other characteristics are commonly shared among persons with either disorder
114
A client reveals that she induces vomiting as often as a dozen times a day. The nurse would expect assessment findings to support which electrolyte imbalance?
Hypokalemia
Vomiting causes loss of potassium, leading to hypokalemia. Vomiting is not the trigger for any of the other options presented.
115
Which coping mechanism is used excessively by clients diagnosed with bulimia nervosa to cope with their obsession with their body image?
Denial
Denial of incongruence between body reality, body ideal, and body presentation is the mainstay of the client diagnosed with bulimia nervosa. None of the other mechanisms are as vital to their coping technique.
116
The nurse working with clients diagnosed with eating disorders can help families develop effective coping mechanisms by implementing which intervention?
Teaching the family about the disorder and the client's behaviors
Families need information about specific eating disorders and the behaviors often seen in clients with these disorders. This information can serve as a basis for additional learning about how to support the family member. While the other options may be appropriate for specific client families, they are not as fundamental as the correct option.
117
A client hospitalized with anorexia nervosa has a weight that is 65% of normal. For this client, what is a realistic short-term goal for the first week of hospitalization regarding the physical impact of his/her weight?
Gain a maximum of 3 lb.
The critical outcome during hospitalization for anorexia nervosa is weight gain. A maximum of 3 pounds weekly is considered sufficient initially. Too-rapid weight gain can cause pulmonary edema. While all the remaining goals are appropriate, none have the physical focus that is the initial priority.
118
Which diagnosis from the list below would be given priority for a client diagnosed with bulimia nervosa?
Risk for injury: electrolyte imbalance
The client who engages in purging and excessive use of laxatives and enemas is at risk for metabolic acidosis from bicarbonate loss. This electrolyte imbalance is potentially life threatening. While appropriate none of the other options are as likely to risk the client's life.
119
Ali is a 17-year-old patient with bulimia coming to the outpatient mental health clinic for counseling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met?
"I am a hard worker and I am very compassionate toward others."
An appropriate overall goal for the bulimic patient would include that the patient be able to identify personal strengths, leading to improved self-esteem. Purging only once a day instead of two is incorrect because the goal is to refrain from purging altogether. A goal is for the patient to express feelings without food references. Purging when alone is incorrect because the patient is still purging.
120
Which disorder is characterized by the client's misinterpretation of physical sensations or feelings?
Illness anxiety disorder
Previously known as hypochondriasis, illness anxiety disorder results in the misinterpretation of physical sensations as evidence of a serious illness. Illness anxiety can be quite obsessive, because thoughts about illness may be intrusive and difficult to dismiss, even when the patient recognizes that his or her fears are unrealistic.
121
Which signs and symptoms are associated with opioid withdrawal?
Lacrimation, rhinorrhea, dilated pupils, and muscle aches.
Symptoms of opioid withdrawal resemble the "flu"; they include runny nose, tearing, diaphoresis, muscle aches, cramps, chills, and fever
122
A client who is dependent on alcohol tells the nurse, "Alcohol is no problem for me. I can quit anytime I want to." The nurse can assess this statement as indicating which defense mechanism?
Denial
Believing that one can control drug use, despite addiction to the substance, is based on denial (escaping unpleasant reality by ignoring its existence
123
The term tolerance, as it relates to substance abuse, refers to which situation?
The need to take larger amounts of a substance to achieve the same effects
With regard to substance abuse, tolerance is defined as the need to take higher and higher doses of a drug to achieve the desired effect. This is the only option that describes the effects of tolerance
124
The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions?
Readiness to change and support system
The plan will take into account acute safety needs, severity and range of symptoms, motivation or readiness to change, skills and strengths, availability of a support system, and the individual's cultural needs.
125
A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital?
Client will be medically stabilized while in the hospital.
If the patient has been abusing substances heavily, he will begin to experience physical symptoms of withdrawal, which can be dangerous if not treated. The priority outcome is for the patient to withdraw from the substances safely with medical support. Substance use disorder outcome measures include immediate stabilization for individuals experiencing withdrawal such as in this instance, as well as eventual abstinence if individuals are actively using, motivation for treatment and engagement in early abstinence, and pursuit of a recovery lifestyle after discharge.
126
Cocaine exerts which of the following effects on a client?
Stimulation and euphoria
Cocaine exerts two main effects on the body, both anesthetic and stimulant
127
Nursing assessment of an alcohol-dependent client 6 to 8 hours after the last drink would most likely reveal the presence of which early sign of alcohol withdrawal?
Tremors
Tremors are an early sign of alcohol withdrawal.
128
What is an appropriate long-term client-centered goal/outcome for a recovering substance abuser.
Abstain from the use of mood-altering substances.
Abstinence is a highly desirable long-term goal/outcome. It is a better outcome than short-term goal because lapses are common in the short term. The remaining options would be considered short-term goals
129
Which information would the nurse share with the client about treatment at a hosptial or day treatment center for OCD
They provide the neutral environment the client needs to work through conflicts
130
Sertraline is prescribed for a client. Which information would the nurse include when teaching the client about this medication
Several weeks may pass before the effects of the medication become evident
131
A person shoplifts merchandise from a community cancer thrift shop. When confronted the person replies, All this stuff is donated so I can take it. This comment suggest features of which personality disorder?
Antisocial
132
A depressed client is given 50mg of Sertraline at bedtime. For which medication related side effects will the nurse monitor for the client?
Dry mouth
Constipation
133
Which characteristic of clients with antisocial personality disorder would the nurse consider when planning care?
Exhibits a lack of empathy for others
134
Which assessment finding would the nurse observe in a client who has been found to have an antisocial personality disorder?
Displays charm, has an above average intelligence and tends to manipulate other
135
A client reports to the nurse,”I’m afraid of every little thing and I have a fear of dying. MY heart races all the time and I break sweats. Which first-line medications would the nurse anticipate developing a teaching plan for?
Sertraline
136
A nurse observes a client who has OCD repeatedly applyin gremoving and then reappplying makeup. The nurse identifies that the behavior in a client who has OCD is due to which of the following underlying reasons.
Attempt to reduce anxiety
137
Which characteristics usually accompany OCD
Doubts, fears, and indecisiveness
138
A mental health nurse assesses a patient diagnosed with an antisocial personality disorder. Which comorbid problem is most important for te nurse to include in the assessment?
Alcohol or substance use disorder
139
The nurse is admitting a client suspected of dissociative amnesia would report which of the following manifestations?
The client’s inability to recall personal information
140
Which nursing intervention would be most important for a client who has the diagnosis of antisocial personality disorder
Providing clear boundaries and consequences
141
Which characteristic distinguishes PTSD from other anxiety disorders?
Reliving the trauma in dreams and flashbacks
142
Which verbalization from a client with dissociative identity disorder who is to be discharged after a 2 week hospital stay indicate the effectiveness of the shor term therapy
The need for long term outpatient psychotherapy
143
Which intervention would the nurse include in the plan of care for a client with posttraumatic stress disorder who verbalizes a desire to have control over personal feelings related to being the only survivor?
Discuss life situations that the client is able to manage
144
A nurse is discussing the factors for somatic symptoms disorder with the newly licensed nurse. Which of the following should the nurse include?
Anxiety Disorder
Childhood Trauma
145
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?
Set realistic limits on the client’s behavior
Clients who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should establish clear limits on specific aggressive and demanding behaviors.
146
A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?
Refrains from manipulating others to earn dining-room privileges.
The goal of operant conditioning is to provide positive reinforcement in return for desired outcome. Refraining from manipulative behavior is a desired outcome
147
A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
“I should practice limit-setting to help prevent client manipulation.”
148
A nurse is assisting with a court‐ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (select all that apply.)
attempts to convince other clients to give him their belongings. exploitation and manipulation of others is an expected finding of antisocial personality disorder.
Blames others for his past and current problems. Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder.
149
Following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to is care and is belligerent when another RN is assigned. What action should the charge RN implement?
Advise the client that assignments are not based on the client’s request.
150
patient taking sertraline (zoloft) for postpartum depression, patient teaching to nurse will provide
contact healthcare provider if having suicidal thoughts (black box warning
151
patient taking sertraline (zoloft) for postpartum depression, patient teaching to nurse will provide
contact healthcare provider if having suicidal thoughts (black box warning
152
Prior to initiating a treatment regimen with the antidepressant sertraline (Zoloft), it is most important for the nurse to obtain which information?
Current weight
153
A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine (SSRI)?
St. John's Wort
St. John's Wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's Wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome.
154
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine (SSRI). Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply.)
Hallucinations.
Diaphoresis.
Agitation.
155
A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication?
“I will need to discontinue this medication slowly.”
156
A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine (SSRI). Which of the following information should the nurse provide? (Select all that apply.)
Administer the medication in the morning.
Monitor for weight loss while taking this medication.
This medication blocks the synaptic reuptake of serotonin in the brain.
157
A nurse is teaching a client who has a depressive disorder about fluoxetine (SSRI). Which of the following information should the nurse include in the teaching?
"You may experience difficulties with sexual functioning while taking this medication."
Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual dysfunction occurs.
158
Fluoxetine is a selective serotonin reuptake inhibitor that can cause ___________ such as anorgasmia and impotence.
sexual dysfunction
159
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." Which of the following responses should the nurse make?
"You sound upset. Are you thinking of hurting yourself?"
This response exemplifies the therapeutic communication technique of showing empathy. Telling the client, "You sound upset," focuses on the client’s feelings, which is a demonstration of therapeutic communication. In addition, the nurse addresses the possibility of suicidal ideation by asking the client directly whether or not she has an intent to harm herself.
160
A nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manages the client’s bruxism? (Select all that apply.)
Concurrent administration of buspirone.
Use of a mouth guard.
Changing to a different class of antianxiety medication.
161
A nurse is caring for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?
Assessing the client's risk for self harm
The greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self-harm or suicide. therefore, the first action the nurse should plan to take is to assess the client’s risk for self-harm to ensure that the client is provided with a safe environment.
162
A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement?
Encourage the client to express her feelings regarding the upcoming procedure.
163
Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
Allow time for the ritualistic behavior, then redirect the client to other activities.
Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability. (B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. (D) lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and resulting ritualistic behavior as treatment progresses.
164
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
Snap a rubber band on your wrist when you think about checking the locks
165
A nurse is providing teaching to the daughter of an older client who has obsessive- compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder?
a. I will limit my mother’s clothing choices when she is getting dressed
b. I will provide my mother with detailed instructions about how to perform self-care
c. I will wake my mother up a couple of times in the night to check on her
d. I will discourage my mother from talking about physical complaints
a. I will limit my mother’s clothing choices when she is getting dressed
166
A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching?
“Talking about the traumatic experience is recommended”
167
A nurse working on an acute mental health unit is caring for a client who has PTSD. Which of the following findings should the nurse expect? (Select all that apply)
Difficulty concentrating on tasks
Negative self-image
Recurring nightmares
168
A school nurse is assessing a school-aged child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)?
Lack of interest in an upcoming holiday
169
A nurse in a community health center is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?
Experiences feelings of isolation.
Clients who have PTSD often feel estranged and detached from others.
170
A nurse in a community health center is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?
Repeatedly talks about the traumatic incident
Sleeps excessively
Experiences feelings of isolation
Uses repetitive speech
Experiences feelings of isolation
Clients who have PTSD often feel estranged and detached from others.
Avoidance of discussing the traumatic event is an expected manifestation of PTSD. Clients who have PTSD have difficulty sleeping and are hypervigilant. Altered speech patterns are not a manifestation of PTSD
171
A school nurse is assessing a school age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder PTSD?
-Clinging behaviors directed toward a teacher
-Increased time spent sleeping
-Intense focus on school work
-Lack of interest in an upcoming holiday
Lack of interest in an upcoming holiday
The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child can also have a loss of interest or lack of participation in significant activities and events such as holidays. The child who has PTSD has difficulty concentrating on tasks. The child who has PTSD exhibits difficulty sleeping and distressing dreams. PTSD manifestations seen in children include detachment or estrangement from others rather than clinging behavior.
172
A male veteran who recently returned from a war zone has post traumatic stress disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicidal ideation. On admission, the client’s family informed the HCP that therapy sessions did not seem to be helping. Select only one intervention that as the highest priority?
Remove all shaving equipment.
173
While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position?
Reinforce reality to the client on the floor and
remove him to a quiet space.
The client who is diagnosed with PTSD is re-experiencing the traumatic experience and needs reality reassurance (confirmation that there is no danger at this time) and reduced stimuli.
174
A woman who is currently being evaluated for post-traumatic stress syndrome (PTSD) after experiencing raped and a stabbing last year has recurrent nightmares and is manifesting a detached affect. Which intervention has the highest priority when the nurse is performing the screening interview? (select only one intervention.)
Ask the client if she has a plan to harm herself
175
PTSD admitted to psychiatric unit, which intervention is most important for plan of care
Provide a quiet rook, away from the recreational area
176
A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (select all that apply.)
Hypokalemia
Slightly elevated body weight. Most clients who have bulimia nervosa maintain a weight within a normal range or slightly higher.
177
A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following response should the nurse make?
“I understand you have concerns about your weight, but first, let’s talk about your recent accomplishments.”
this statement acknowledges the client’s concern and then focuses the conversation on the client’s accomplishments, which can promote client self‐esteem and self‐image.
178
A nurse is assessing a pt who has bulimia nervosa. The nurse should expect which of the following findings
Tooth erosion
A client who has bulimia nervosa is likely to have dental carries and tooth erosion caused by frequent exposure to gastric acid from vomiting.
179
A nurse in an ER is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter’s diagnosis?
"She works so hard at ballet. Will she still be able to perform?"
"She won't let me take the trash from her room. I'm concerned about what she has in there."
"She told me she was tired, so I did her chores for her today."
"She is happier with her appearance now that she's lost some weight."
"She won't let me take the trash from her room. I'm concerned about what she has in there."
The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother's statement indicates awareness of her daughter's behavior
180
A nurse is teaching the guardians of a client about their adolescent child’s diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child’s illness?
-"This disease will increase our child's risk for high blood pressure."
-"It is important for our child to have regular dental checkups."
-"We need to weigh our child daily for several weeks, then once per week."
-"Bleeding during our child's periods will increase because of this disease."
-"It is important for our child to have regular dental checkups."
For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups are important for a client who has bulimia nervosa
181
A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan?
-Identify the client's trigger foods.
The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.
182
What is the most important intervention for a client with bulimia?
* Plan scheduled meals.
183
The nurse has identified the diagnosis imbalance Nutrition: More than body requirements for a client diagnosed with bulimia. Which intervention would be appropriate for this diagnosis?
* Help client assess situations that precedes binging
184
A nurse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect?
Acrocyanosis
185
A nurse at a college campus health clinic is caring for a client who reports manifestations of bulimia nervosa. The client tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot control it." Which of the following responses should the nurse make?
"Why do you think you are experiencing these behaviors of binges and vomiting?"
"Are other students in your dorm also experiencing this behavior?”
"You are feeling helpless about changing this behavior?"
"You know you must stop because you are endangering your health."
"You are feeling helpless about changing this behavior?"
The nurse should use the therapeutic communication technique of restating when responding to the feelings the client has expressed. Restating focuses on the main idea of the client’s statement and helps the client understand and explore personal behaviors.
186
A nurse is admitting a pt who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?
Encourage the client to drink 125 mL of fluid each hour while awake.
The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration.
187
A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?
"You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."
The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.
188
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?
Orthostatic hypotension
Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension
189
A client who has anorexia nervosa is more likely to have _______ resulting from extreme malnutrition.
Lanugo
190
A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?
Suggest another way for this client to participate in unit activities.
Anorexics gain pleasure from providing others with food and watching them eat. Such behaviors reinforce their perception of self-control. These clients should not be allowed to plan or prepare food for unit activities and their desires to do so should be redirected (C). (A and B) are contraindicated for a client with anorexia nervosa. (D) avoids addressing the problem and is manipulative in that the nurse is blaming hospital policy for treatment protocol.
191
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Notify the client about designated time for meals
192
The nurse is interviewing a client who has Anorexia Nervosa. Which if the following findings should the nurse expect?
Strenuous exercise regimen
The nurse should expect the client who has anorexia nervosa to report a strenuous exercise regimen. The client might participate in excessive physical activity due to the perceived need to burn calories and lose weight.
193
A nurse is performing an admission assessment for a client who has restricting type Anorexia Nervosa. The nurse should expect which of the following findings?
Decreased caloric intake
The nurse should expect the client who has restricting type anorexia nervosa to have a restricted and decreased caloric intake due to the client’s intense fear of weight gain.
194
A nurse is developing a plan of care with a client who has Anorexia Nervosa. The nurse should identify that which of the following actions is contraindicated for this client?
Permitting the client to spend some quiet time alone after each meal
The nurse should directly observe the client for a minimum of 1 hr following meals. This intervention prevents the client from purging or discarding hidden food. Therefore, permitting the client to have alone time following meals is contraindicated for his plan of care.
195
A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics?
Possesses feelings of decreased self-worth
The nurse should expect the client who has anorexia nervosa to have an altered sense of self- image and self-identity. The client often bases feelings of self-worth on body weight; therefore, feelings of self-worth are often decreased because the client views herself as overweight.
196
A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse to include in the assessment? (select all that apply.)
“What is your relationship like with your family?” A nursing history of a client who has anorexia nervosa should include an assessment of family and interpersonal relationships.
“Would you describe your current eating habits?”
“Can you discuss your feelings about your appearance?”
197
A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing?
“Life isn’t worth living if I gain weight.”
This statement reflects the cognitive distortion of catastrophizing because the client’s perception of her appearance or situation is much worse than her current condition.
198
A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge‐eating and purging behavior. Which of the following nursing actions should the nurse include in the client’s plan of care?
implement one‐to‐one observation during meal times.
The nurse should closely monitor the client during and after meals to prevent purging.
199
A nurse is assessing a client who has Binge-Eating Disorder. Which of the following findings should the nurse expect?
Abdominal pain
The nurse should expect the client who has binge-eating disorder to report problems with abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating excessive volumes of food.
200
A nurse on an acute care unit is providing postoperative care for an elderly patient who
developed Delirium. Which of the following actions should the nurse take?
Request a prescription for an antianxiety medication.
The nurse should request a prescription for an antianxiety medication for a client who develops delirium. Administration of a PRN antianxiety medication can decrease her anxiety and agitation.
201
A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?
Rapid mood swings
202
A nurse is performing an admission assessment for a client who has delirium related to an acute UTI. Which of the following findings should the nurse expect? (Select all that apply)
Family report of personality changes
Hallucinations
Restlessness
203
A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client’s plan of care?
Permit the client to perform daily rituals to decrease anxiety
204
A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?
Easily distracted
Extreme distractibility is a hallmark manifestation of delirium. Delirium has an acute onset. Dementia is a slow, progressive decline. Aphasia and confabulation are a manifestation of dementia.
205
A nurse is caring for an older adult client who is experiencing delirium. Which of the following intervention should the nurse include in the clients plan of care?
Offer the client various choices for meal selection.
-Assign different nursing personnel for each shift.
-Permit the client to perform daily rituals to decrease anxiety.
-Maintain an environment that has low lighting.
-Permit the client to perform daily rituals to decrease anxiety.
Allowing clients who have delirium to practice daily rituals will decrease frustration and anxiety.
206
A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable?
Monitor vital signs
207
A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia?
Delirium: Started in hospital
208
A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
a. Reinforce the clients orientation with the calendar
b. Refute the clients perception of visual hallucinations
c. Teach the client assertive techniques
d. Assigned the client to a different caregiver each shift
a. Reinforce the clients orientation with the calendar
209
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?
a. The client is unable to recognize objects.
b. The client manifestations developed suddenly
c. The client has a flat affect
d. The client’s speech is slow and repetitious
b. The client manifestations developed suddenly
210
A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation?
older adults are at an increased risk for substance use following retirement.
211
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply.)
Fine tremors of both hands
vomiting
restlessness
212
A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicate an understanding of the teaching? (Select all that apply.)
“eliminating any codependent behavior will promote her recovery.”
“The primary goal of her treatment is abstinence from substance use.”
“She needs to discuss her feelings about substance use to help her recover
213
A nurse on a medsurg unit is assessing a pt who sustained injuries 12 hrs ago following a motor vehicle crash. The pt’s blood alcohol level was 325mg/dL. Which of the following findings should indicate to the nurse that the pt is experiencing alcohol withdrawl?
Blood pressure 154/96 mm Hg
Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever.
214
A nurse is caring for a pt who has attempted suicide and has alcohol use disorder. Which of the following statements indicates that the pt is using a positive coping mechanism?
"I will attend daily group therapy sessions to practice relaxation techniques."
Relaxation techniques decrease the risk for self-harm by decreasing stress, anxiety, and depression.
215
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?
-"I am able to go to work every day, so I don't have a problem."
By insisting that his drinking is not a problem because he can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of his substance use disorder.
216
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?
-"I put in extra hours at work so I won't think about drinking."
-"I know that wine is good for my heart, so that's why I drink some each evening."
-"I make up for my drinking by taking my partner on nice vacations."
-"I am able to go to work every day, so I don't have a problem."
-"I am able to go to work every day, so I don't have a problem."
By insisting that his drinking is not a problem because he can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of his substance use disorder.
217
A nurse in a mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include?
-Attending a relapse prevention group several times each week
The most effective strategy for relapse prevention is a 12-step program, such as Alcoholics
218
A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
Place in a side-lying position with head of bed elevated.
219
A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take
Ask client about alcohol quantity, frequency, and time of last drink
220
A nurse in a substance abuse treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer Methadone for a client who has a substance use disorder for which of the following addictions?
Opiates
The nurse should recognize that the administration of methadone is indicated for the treatment of opiate use disorder. Opiates include opium, morphine, codeine, methadone, and heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of opiate withdrawal
221
The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal?
Psychomotor agitation
During cocaine withdrawal, the nurse should expect psychomotor agitation and a pattern of withdrawal symptoms similar to those of one who uses amphetamines
222
The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal?
Psychomotor agitation
During cocaine withdrawal, the nurse should expect psychomotor agitation and a pattern of withdrawal symptoms similar to those of one who uses amphetamines
223
An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens?
Restlessness and confusion
A client experiencing alcohol withdrawal often has delirium tremens (DTs), which are characterized by progressive disorientation. Initially, the client will appear restless and confused and develop tachycardia, tachypnea, and diaphoresis.
224
What is a common side effect of cocaine use.
Heart attack.
225
A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal?
Fatigue
226
A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect?
Dilated pupils
Dilated pupils are associated with the use of cocaine.
227
A nurse in an emergency department is assessing a client who reports recently using cocaine. Which of the following clinical manifestations should the nurse expect?
a. Lethargy
b. Hypothermia
c. Hypertension
d. Bradycardia
Hypertension
Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body temperature, energy levels, and metabolism.
228
A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior?
A. The client asks the nurse whether she will go out
to dinner with him.
B. The client accuses the nurse of telling him what to do
just like his ex-girlfriend.
C. The client reminds the nurse of a friend who died from
a substance overdose.
D. The client becomes angry and threatens harm to himself.
B. The client accuses the nurse of telling him what to do
just like his ex-girlfriend.
229
A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?
"Acquaintance rape often involves alcohol."
230
The nurse is interviewing a client who has Anorexia Nervosa. Which if the following findings should the nurse expect?
Strenuous exercise regimen
The nurse should expect the client who has anorexia nervosa to report a strenuous exercise regimen. The client might participate in excessive physical activity due to the perceived need to burn calories and lose weight.
231
A nurse is caring for a client who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "Don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent?
Offering false reassurance
