Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:
Alcoholics anonymous (A.A.)
Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:
Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…
Give her privacy
Allow her to urinate
Open the window and allow her to get some fresh air
Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?
Provide privacy during meals
Set-up a strict eating plan for the client
Encourage client to exercise to reduce anxiety
Restrict visits with the family
A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
Turning on the television
Leaving the client alone
Staying with the client and speaking in short sentences
Ask the client to play with other clients
A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
Highly famous and important
Responsible for evil world
Connected to client unrelated to oneself
A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?
Recurrent self-destructive behavior
Showing interest in solitary activities
Inability to make choices and decision without advise
A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?
Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?
Encourage to avoid foods
Identify anxiety causing situations
Eat only three meals a day
Avoid shopping plenty of groceries
Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?
Generates new levels of awareness
Assumes responsibility for her actions
Has maximum ability to solve problems and learn new skills
Her perception are based on reality
A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?
Nausea and vomiting
A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
Apathetic response to the environment
“I don’t know” answer to questions
Shallow of labile effect
Neglect of personal hygiene
Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?
Teach client to measure I & O
Involve client in planning daily meal
Observe client during meals
Monitor client continuously
Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?
Cardiac dysrhythmias resulting to cardiac arrest
Glucose intolerance resulting in protracted hypoglycemia
Endocrine imbalance causing cold amenorrhea
Decreased metabolism causing cold intolerance
Nurse Anna can minimize agitation in a disturbed client by?
limiting unnecessary interaction
increasing appropriate sensory perception
ensuring constant client and staff contact
A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
Problems with being too conscientious
Problems with anger and remorse
Feelings of guilt and inadequacy
Feeling of unworthiness and hopelessness
Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
Allowing a snack to be kept in his room
Reprimanding the client
Ignoring the clients behavior
Setting limits on the behavior
Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
Ask a family member to stay with the client at home temporarily
Discuss the meaning of the client’s statement with her
Request an immediate extension for the client
Ignore the clients statement because it’s a sign of manipulation
Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?
Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?
Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?
Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?
Yawning & diaphoresis
Restlessness & Irritability
Constipation & steatorrhea
Vomiting and Diarrhea
To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?
Encourage the staff to have frequent interaction with the client
Share an activity with the client
Give client feedback about behavior
Respect client’s need for personal space
Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
Manipulate the environment to bring about positive changes in behavior
Allow the client’s freedom to determine whether or not they will be involved in activities
Role play life events to meet individual needs
Use natural remedies rather than drugs to control behavior
Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
Have more positive relation with the father than the mother
Cling to mother & cry on separation
Be able to develop only superficial relation with the others
Have been physically abuse
When teaching parents about childhood depression Nurse Trina should say?
It may appear acting out behavior
Does not respond to conventional treatment
Is short in duration & resolves easily
Looks almost identical to adult depression
Nurse Perry is aware that language development in autistic child resembles:
A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?
When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?
Anxiety when discussing phobia
Anger toward the feared object
Denying that the phobia exist
Distortion of reality when completing daily routines
Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
Would you like to watch TV?
Would you like me to talk with you?
Are you feeling upset now?
Ignore the client
Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:
Avoidance of situation & certain activities that resemble the stress
Depression and a blunted affect when discussing the traumatic situation
Lack of interest in family & others
Re-experiencing the trauma in dreams or flashback
Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?
Flight of ideas
Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?
Excessive activity, memory lapses & an increased pulse
A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
Frequent regurgitation & re-swallowing of food
Previous history of gastritis
Badly stained teeth
Positive body image
Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:
Minimal decision making
To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of:
Frustration & fear of death
Anger & resentment
Anxiety & loneliness
Helplessness & hopelessness
A nursing care plan for a male client with bipolar I disorder should include:
Providing a structured environment
Designing activities that will require the client to maintain contact with reality
Engaging the client in conversing about current affairs
Touching the client provide assurance
When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
Helps the client focus on the inability to deal with reality
Helps the client control the anxiety
Is under the client’s conscious control
Is used by the client primarily for secondary gains
A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
Low self esteem
Effective self boundaries
A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:
Flight of ideas
Loosening of association
A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
Insight into his behavior
Better self control
Feeling of self worth
Faith in his wife
A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
Focusing on self-disclosure of own food preference
Using open ended question and silence
Offering opinion about the need to eat
Verbalizing reasons that the client may not choose to eat
Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
Ask the client direct questions to encourage talking
Rake the client into the dayroom to be with other clients
Sit beside the client in silence and occasionally ask open-ended question
Leave the client alone and continue with providing care to the other clients
Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
“You’re having hallucination, there are no spiders in this room at all”
“I can see the spiders on the wall, but they are not going to hurt you”
“Would you like me to kill the spiders”
“I know you are frightened, but I do not see spiders on the wall”
Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
“Abuse occurs more in low-income families”
“Abuser Are often jealous or self-centered”
“Abuser use fear and intimidation”
“Abuser usually have poor self-esteem”
During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
Anesthesia is administered during the procedure
Decrease oxygen to the brain increases confusion and disorientation
Grand mal seizure activity depresses respirations
Muscle relaxations given to prevent injury during seizure activity depress respirations.
When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
The client eliminates all anxiety from daily situations
The client ignores feelings of anxiety
The client identifies anxiety producing situations
The client maintains contact with a crisis counselor
Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?
Short term seclusion
Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
Length of time on the med.
Name of the ingested medication & the amount ingested