Review Questions

Question 1

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?

Answer 1

Initiative one-to-one observation of the client.

Question 2

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?

Answer 2

The client is a danger to herself or others

Question 3

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?

Answer 3

Faise imprisonment

Question 4

A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

Answer 4

An adult dient following a suicide attempt

Question 5

Which nursing objective would be essential in the therapeutic psychiatric environment for a confused cleint?

Answer 5

Maintaining the highest level of safe, independent function

Question 6

A registered nurse is educating a nursing student about community health nursing. Which point made by the student nurse needs correction?

Answer 6

Community health psychiatric nursing does not provide direct or indirect care services to subpopulations in a community

Question 7

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)

Answer 7

Restlessness, tachycardia, fever, diarrhea, and altered mental status

Question 8

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?

Answer 8

1 understand that you are angry. However, I followed the appropriate protocol.”

Question 9

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?

Answer 9

Tell the nurse to stop discussing the behavior

Question 10

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?

Answer 10

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.

Question 11

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?

Answer 11

Ask the client to verbalize an understanding of the outcomes of the procedure

Question 12

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Answer 12

Secure the restraints using a quick-release tie. Secure the restraints using a quick-release tie.

Question 13

A newly admitted shy, withdrawn adolescent boy asks an experienced female psychiatric nurse for initial response will the nurse use?

Answer 13

Restate the purpose of the nurse-client relationship

Question 14

Which information is accurate regarding the role of value clarification in the resolution of psychiatric ethical dilemmas?

Answer 14

Tolerating differences of opinion

Question 15

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.

Answer 15

Paternalism

Question 16

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?

Answer 16

Obtain consent from a person legally authorized to give it on the client’s behalf, it available

Question 17

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?

Answer 17

Reflection

Question 18

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?

Answer 18

Asking for explanation

Question 19

Which characteristic would be the most helpful for an individual client to gain therapeutic benefits from group therapy?

Answer 19

Ability to recognize own problems

Question 20

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?

Answer 20

“Clients who are involuntarily admitted have the right to informed consent.”

Question 21

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?

Answer 21

“You must be very upset about something.”

Question 22

A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intevention?

Answer 22

Preparing for artificial ventilation

Question 23

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.)

Answer 23

Gender
Perception
Education

Question 24

Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication?

Answer 24

Offering advice

Question 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?

Answer 25

Set behavioral limits for the client.

Question 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?

Answer 26

It must be very difficult for you to be on a psychiatric unit

Question 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?

Answer 27

The client follows directions.

Question 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.)

Answer 28

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

Question 29

Which scenarios relate to the psychiatric nurse’s commitment to ethics and fidelity in practice? (Select all that Apply)

Answer 29

“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.”

Question 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?

Answer 30

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.

Question 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.

Answer 31

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

Question 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?

Answer 32

Autonomy

Question 33

Which statement is true of the relationship between bipolar disorder and suicide?

Answer 33

Suicide is a serious risk for nealry 20% of those diagnosed with bipolar disorder commint suicide

Question 34

Which factor would be discussed when nurse educating a patient about bulimia nervosa is correct? (Select all that Apply)

Answer 34

Mnemonic REM

Relaxation Techniques
Effects of poging
Meal Planning

Question 35

Which consideration must the nurse make before lithium can be started when planning care for a patio twho has mania.

Answer 35

The physical examination and laboratory tests are analyzed

Question 36

Which classic characteristic is common among patients diagnosed with bulimia nervosa?

Answer 36

Onset in late adolescence

Question 37

Which intervention would be included in the plan of care for a patient who takes lithium?

Answer 37

Conducting periodic laboratory monitoring of renal and thyroid function

Question 38

Which action would the nurse take for a patient taking lithium carbonate who repeatedly requests water to drink and has slurred speech?

Answer 38

Evaluate the patient’s blood lithium level

Question 39

Which clinical manifestation is identified as a symptom of anorexia nervosa ( Select all that apply)

Answer 39

Emaciation
Dehydration
Yellow Skin

Question 40

Which sign or symptoms would the nurse expect a patient with a diagnosis of binge-eating disorder to exhibit

Answer 40

Obesity (also purging)

Question 41

Which nursing action is appropriate when caring for a patient diagnosed with bulimia nervosa?

Answer 41

Monitor the patient’s bathroom trips after meals

Question 42

Which statement regarding therapy with lithium is true? (Select All that apply)

Answer 42

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

Question 43

Which assessment will the nurse perform on a patient suspected of having bulimia

Answer 43

Inspection of the oral cavity

Question 44

A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa?

Answer 44

I have lost 60 pounds but I am still a size 1, want to be a size 0

Question 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?

Answer 45

I’ve had bad diarrhea for 3 days

Question 46

Which symptom is most commonly seen in clients diagnosed with bipolar II disorder and experiencing hypomania?

Answer 46

Hyperactivity and high energy

Question 47

Which laboratory values would be assessed for, in a patient taking lithium?

Answer 47

Sodium level

Question 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?

Answer 48

Mania can result in irresponsible and physically risky behaviors

Question 49

A nurse is caring for a client who has bipolar disorder. Which of the following is the proirity nursing action?

Answer 49

Monitor the client for escalating behavior

Question 50

Which patient responses is indicative of suicidal ideation?

Answer 50

I fell like sleeping forever and never waking up again

Question 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.

Answer 51

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

Question 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?

Answer 52

I am here to provide care and cannot accept this from you

Question 53

Which finding would cause the nurse to hold a dose of lithium for a patient with bipolar disorder?

Answer 53

Coarse hand tremors

Question 54

A patient diagnosed with bipolar disorder and which additional acondition canbe safely prescribed lithium therapy

Answer 54

Erectile dysfunction

Question 55

Which comment by a patient diagnosed with bipolar disorder indicates the patient is experiencing mania?

Answer 55

Yesterday I made 487 posts on my social network page

Question 56

Which assessment question would the nurse ask a patient who has a suspected diagnosis of anorexia

Answer 56

How would you describe your body

Question 57

Which condition is an advanced but not severe sign of lithium toxicity

Answer 57

Mental confusion

Question 58

Which patient would be a candidate for ECT?

Answer 58

Has tried five different antidepressants with poor response

Question 59

Which goals are appropriate for all patients diagnosed with an eating disorder? (Select all that Apply)

Answer 59

Restore nutritional state
Modify disordered eating behavior
Help change distorted beliefs about body image

Question 60

A patient diagnosed with bulimia nervosa frequently uses enamas and laxatives to purge. Which imbalance might be present with this patient?

Answer 60

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.

Question 61

Which finding reflects appropriate information to include when documenting the assessment and care provided in the record of patient admitted with bipolar disorder?

Answer 61

Patient states, “I do not want to talk about it”

Question 62

Which instruction would the nurse include on the diet chart for a patient who has mania

Answer 62

Take lithium with meals

Question 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?

Answer 63

Consider the need to obtain a lithium level from the laboratory. The patient may not be swallowing the medication

Question 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?

Answer 64

Initiate one to one observation of the client

Question 65

Which type of mental health disorder is most likely to include an assessment for presence of secondary gain?

Answer 65

Somatic Symptom Disorder

Question 66

Which approach would the nurse use for a client with an OCD to decrease the use of ritualistic behavior?

Answer 66

Attempting to limit situations that will worsen the anxiety

Question 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.)

Answer 67

obsessive thoughts about disease
History of childhood abuse
avoidance of health care providers
depressive disorder

Question 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?

Answer 68

Attempt to reduce anxiety.

Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety.

Question 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.)

Answer 69

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

Question 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)

Answer 70

Explore anxiety provoking situations
Assist the client in examining coping mechanisms

Question 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?

Answer 71

Limit the number of times hand washing occurs

Question 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?

Answer 72

Develop a routine schedule of activities

Question 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?

Answer 73

In the morning

Question 74

Most people can’t help the fact that they hoard because it is a behavior that is what

Answer 74

Compulsive

Question 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.

Answer 75

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.

Question 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?

Answer 76

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.

Question 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?

Answer 77

Report the client’s serum lithium level to the HCP.

Question 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?

Answer 78

Prior to giving the next dose, notify the physician of the symptoms.

Question 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?

Answer 79

Nausea and vomiting.

Question 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?

Answer 80

drink 2-3L of water in 24 hours

Question 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

Answer 81

Lithium is excreted by the kidneys and creatinine is related to functioning

Question 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?

Answer 82

Lithium level routinely.

Question 83

What are the side effects of Lithium?

Answer 83

Dehydration, diarrhea, and thirstiness.

Question 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?

Answer 84

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).

Question 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?

Answer 85

Administer the next does of lithium

Question 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 86

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.

Question 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?

Answer 87

“I will call my doctor if I have diarrhea”

Question 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?

Answer 88

“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.

Question 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 89

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.

Question 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.”

Answer 90

“Regular aspirin would be a better choice than ibuprofen.”

Question 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.)

Answer 91

Polyuria.
Muscle weakness.

Question 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.”

Answer 92

“My mother is currently on furosemide for her congestive heart failure.”

Question 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?

Answer 93

-“Take this medication with food.”

Lithium can cause gastrointestinal distress. Therefore, this medication should be taken with foo

Question 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.

Answer 94

Lithium

Question 95

Extreme distractibility is a hallmark manifestation of _______.

Answer 95

delirium

Question 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.

Answer 96

lithium toxicity

Question 97

Lithium can cause gastrointestinal distress. Therefore, this medication should be taken ___________.

Answer 97

with food.

Question 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?

Answer 98

Escort the client to a quieter place.

Question 99

In the mental health field, hoarding is considered a tya symptom of what ?

Answer 99

An anxiety disorder

Question 100

The nurse conducts a patient teaching on th side effects of Sertraine. Which side effect would the nurse teach the patient?

Answer 100

Being unable to sleep

Question 101

For a client with OCD which event will increase the client’s anxiety level?

Answer 101

Limits are set on the performance of a ritual

Question 102

Which client response would the nurse anticipate when an attempt is made to prevent an OCD client from carrying out a ritualistic behavior?

Answer 102

Anger

Question 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?

Answer 103

Decrease the number of verbal outbursts

Question 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?

Answer 104

The client recognizes the importance of others

Question 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)

Answer 105

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

Question 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?

Answer 106

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

Question 107

A nurse is assessing a client who has antisocial personality disorder. Which of the following client behaviors should the nurse expect?

Answer 107

Manipulative

Question 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)

Answer 108

Attempts to convince other clients to give him their belongings
Blames others for his past and current problems

Question 109

School age children who have conduct disorder, choldhood onset type are at high rsk for progression gto which disorder during adolescense?

Answer 109

Antisocial Personality

Question 110

Which statement by the client would alert the nurse the client is experiencing a somatic delusion?

Answer 110

My stomach has disintegrated

Question 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?

Answer 111

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

Question 112

Which subjective symptom should the nurse would expect to note during assessment of a client diagnosed with anorexia nervosa?

Answer 112

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

Question 113

The client experiencing bulimia differs from the client diagnosed with anorexia nervosa by exhibiting which characteristic?

Answer 113

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

Question 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?

Answer 114

Hypokalemia

Vomiting causes loss of potassium, leading to hypokalemia. Vomiting is not the trigger for any of the other options presented.

Question 115

Which coping mechanism is used excessively by clients diagnosed with bulimia nervosa to cope with their obsession with their body image?

Answer 115

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.

Question 116

The nurse working with clients diagnosed with eating disorders can help families develop effective coping mechanisms by implementing which intervention?

Answer 116

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.

Question 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?

Answer 117

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.

Question 118

Which diagnosis from the list below would be given priority for a client diagnosed with bulimia nervosa?

Answer 118

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.

Question 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?

Answer 119

“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.

Question 120

Which disorder is characterized by the client’s misinterpretation of physical sensations or feelings?

Answer 120

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.

Question 121

Which signs and symptoms are associated with opioid withdrawal?

Answer 121

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

Question 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?

Answer 122

Denial

Believing that one can control drug use, despite addiction to the substance, is based on denial (escaping unpleasant reality by ignoring its existence

Question 123

The term tolerance, as it relates to substance abuse, refers to which situation?

Answer 123

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

Question 124

The treatment team meets to discuss a client’s plan of care. Which of the following factors will be priorities when planning interventions?

Answer 124

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.

Question 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?

Answer 125

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.

Question 126

Cocaine exerts which of the following effects on a client?

Answer 126

Stimulation and euphoria

Cocaine exerts two main effects on the body, both anesthetic and stimulant

Question 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?

Answer 127

Tremors

Tremors are an early sign of alcohol withdrawal.

Question 128

What is an appropriate long-term client-centered goal/outcome for a recovering substance abuser.

Answer 128

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

Question 129

Which information would the nurse share with the client about treatment at a hosptial or day treatment center for OCD

Answer 129

They provide the neutral environment the client needs to work through conflicts

Question 130

Sertraline is prescribed for a client. Which information would the nurse include when teaching the client about this medication

Answer 130

Several weeks may pass before the effects of the medication become evident

Question 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?

Answer 131

Antisocial

Question 132

A depressed client is given 50mg of Sertraline at bedtime. For which medication related side effects will the nurse monitor for the client?

Answer 132

Dry mouth
Constipation

Question 133

Which characteristic of clients with antisocial personality disorder would the nurse consider when planning care?

Answer 133

Exhibits a lack of empathy for others

Question 134

Which assessment finding would the nurse observe in a client who has been found to have an antisocial personality disorder?

Answer 134

Displays charm, has an above average intelligence and tends to manipulate other

Question 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?

Answer 135

Sertraline

Question 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.

Answer 136

Attempt to reduce anxiety

Question 137

Which characteristics usually accompany OCD

Answer 137

Doubts, fears, and indecisiveness

Question 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?

Answer 138

Alcohol or substance use disorder

Question 139

The nurse is admitting a client suspected of dissociative amnesia would report which of the following manifestations?

Answer 139

The client’s inability to recall personal information

Question 140

Which nursing intervention would be most important for a client who has the diagnosis of antisocial personality disorder

Answer 140

Providing clear boundaries and consequences

Question 141

Which characteristic distinguishes PTSD from other anxiety disorders?

Answer 141

Reliving the trauma in dreams and flashbacks

Question 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

Answer 142

The need for long term outpatient psychotherapy

Question 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?

Answer 143

Discuss life situations that the client is able to manage

Question 144

A nurse is discussing the factors for somatic symptoms disorder with the newly licensed nurse. Which of the following should the nurse include?

Answer 144

Anxiety Disorder
Childhood Trauma

Question 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?

Answer 145

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.

Question 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?

Answer 146

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

Question 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?

Answer 147

“I should practice limit-setting to help prevent client manipulation.”

Question 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.)

Answer 148

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.

Question 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?

Answer 149

Advise the client that assignments are not based on the client’s request.

Question 150

patient taking sertraline (zoloft) for postpartum depression, patient teaching to nurse will provide

Answer 150

contact healthcare provider if having suicidal thoughts (black box warning

Question 151

patient taking sertraline (zoloft) for postpartum depression, patient teaching to nurse will provide

Answer 151

contact healthcare provider if having suicidal thoughts (black box warning

Question 152

Prior to initiating a treatment regimen with the antidepressant sertraline (Zoloft), it is most important for the nurse to obtain which information?

Answer 152

Current weight

Question 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)?

Answer 153

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.

Question 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.)

Answer 154

Hallucinations.
Diaphoresis.
Agitation.

Question 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?

Answer 155

“I will need to discontinue this medication slowly.”

Question 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.)

Answer 156

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.

Question 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?

Answer 157

“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.

Question 158

Fluoxetine is a selective serotonin reuptake inhibitor that can cause ___________ such as anorgasmia and impotence.

Answer 158

sexual dysfunction

Question 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?

Answer 159

“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.

Question 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.)

Answer 160

Concurrent administration of buspirone.
Use of a mouth guard.
Changing to a different class of antianxiety medication.

Question 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?

Answer 161

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.

Question 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?

Answer 162

Encourage the client to express her feelings regarding the upcoming procedure.

Question 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?

Answer 163

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.

Question 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?

Answer 164

Snap a rubber band on your wrist when you think about checking the locks

Question 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

Answer 165

a. I will limit my mother’s clothing choices when she is getting dressed

Question 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?

Answer 166

“Talking about the traumatic experience is recommended”

Question 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)

Answer 167

Difficulty concentrating on tasks
Negative self-image
Recurring nightmares

Question 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)?

Answer 168

Lack of interest in an upcoming holiday

Question 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?

Answer 169

Experiences feelings of isolation.

Clients who have PTSD often feel estranged and detached from others.

Question 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

Answer 170

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

Question 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

Answer 171

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.

Question 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?

Answer 172

Remove all shaving equipment.

Question 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?

Answer 173

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.

Question 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.)

Answer 174

Ask the client if she has a plan to harm herself

Question 175

PTSD admitted to psychiatric unit, which intervention is most important for plan of care

Answer 175

Provide a quiet rook, away from the recreational area

Question 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.)

Answer 176

Hypokalemia

Slightly elevated body weight. Most clients who have bulimia nervosa maintain a weight within a normal range or slightly higher.

Question 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?

Answer 177

“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.

Question 178

A nurse is assessing a pt who has bulimia nervosa. The nurse should expect which of the following findings

Answer 178

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.

Question 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.”

Answer 179

“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

Question 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.”

Answer 180

-“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

Question 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?

Answer 181

-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.

Question 182

What is the most important intervention for a client with bulimia?

Answer 182

• Plan scheduled meals.

Question 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?

Answer 183

• Help client assess situations that precedes binging

Question 184

A nurse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect?

Answer 184

Acrocyanosis

Question 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.”

Answer 185

“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.

Question 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?

Answer 186

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.

Question 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?

Answer 187

“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.

Question 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?

Answer 188

Orthostatic hypotension

Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension

Question 189

A client who has anorexia nervosa is more likely to have _______ resulting from extreme malnutrition.

Answer 189

Lanugo

Question 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?

Answer 190

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.

Question 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?

Answer 191

Notify the client about designated time for meals

Question 192

The nurse is interviewing a client who has Anorexia Nervosa. Which if the following findings should the nurse expect?

Answer 192

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.

Question 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?

Answer 193

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.

Question 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?

Answer 194

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.

Question 195

A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics?

Answer 195

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.

Question 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.)

Answer 196

“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?”

Question 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?

Answer 197

“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.

Question 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?

Answer 198

implement one‐to‐one observation during meal times.

The nurse should closely monitor the client during and after meals to prevent purging.

Question 199

A nurse is assessing a client who has Binge-Eating Disorder. Which of the following findings should the nurse expect?

Answer 199

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.

Question 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?

Answer 200

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.

Question 201

A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?

Answer 201

Rapid mood swings

Question 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)

Answer 202

Family report of personality changes
Hallucinations
Restlessness

Question 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?

Answer 203

Permit the client to perform daily rituals to decrease anxiety

Question 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?

Answer 204

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.

Question 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.

Answer 205

-Permit the client to perform daily rituals to decrease anxiety.

Allowing clients who have delirium to practice daily rituals will decrease frustration and anxiety.

Question 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?

Answer 206

Monitor vital signs

Question 207

A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia?

Answer 207

Delirium: Started in hospital

Question 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

Answer 208

a. Reinforce the clients orientation with the calendar

Question 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

Answer 209

b. The client manifestations developed suddenly

Question 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?

Answer 210

older adults are at an increased risk for substance use following retirement.

Question 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.)

Answer 211

Fine tremors of both hands
vomiting
restlessness

Question 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.)

Answer 212

“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

Question 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?

Answer 213

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.

Question 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?

Answer 214

“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.

Question 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?

Answer 215

-“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.

Question 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.”

Answer 216

-“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.

Question 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?

Answer 217

-Attending a relapse prevention group several times each week
The most effective strategy for relapse prevention is a 12-step program, such as Alcoholics

Question 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?

Answer 218

Place in a side-lying position with head of bed elevated.

Question 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

Answer 219

Ask client about alcohol quantity, frequency, and time of last drink

Question 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?

Answer 220

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

Question 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?

Answer 221

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

Question 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?

Answer 222

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

Question 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?

Answer 223

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.

Question 224

What is a common side effect of cocaine use.

Answer 224

Heart attack.

Question 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?

Answer 225

Fatigue

Question 226

A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect?

Answer 226

Dilated pupils
Dilated pupils are associated with the use of cocaine.

Question 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

Answer 227

Hypertension

Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body temperature, energy levels, and metabolism.

Question 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.

Answer 228

B. The client accuses the nurse of telling him what to do
just like his ex-girlfriend.

Question 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?

Answer 229

“Acquaintance rape often involves alcohol.”

Question 230

The nurse is interviewing a client who has Anorexia Nervosa. Which if the following findings should the nurse expect?

Answer 230

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.

Question 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?

Answer 231

Offering false reassurance