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The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. Neglecting personal grooming. A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me.“ Which response by the nurse demonstrates therapeutic communication? You have everything to live for." "Why do you see yourself as a failure?". "Feeling like this is all part of being depressed.". The nurse visits a client at home. The client states, "] haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? I see." "Really?" | "Sometimes I have trouble sleeping too." A client experiencing disturbed thought processes believes that his foad is being poisoned. Which communication technique should the nurse use to encourage the client o ° oO » tad S (encourage the client to express feelings) Sharing personal preference regarding food choices Documenting reasons why the client does not want to eat Offering opinions about the necessity of adequate nutrition The nurse should plan which goals of the termination stage of group development? Select all that apply. The real work of the group is accomplished. Group interaction involves superficial conversation. Group members become acquainted with one another. Some structuring of group norms, roles, and responsibilities takes place. A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and | wish my family would stop hoping for a cure! | get so angry when they carry on like this. After all, I'm the one who's dying.” Which response by the nurse is therapeutic? Have you shared your feelings with your family?" "| think we should talk more about your anger with your family." "You are probably very depressed, which is understandable with such a diagnosis." On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior? Fearfulness regarding treatment measures Anger and aggressiveness directed toward others An understanding of the pathology and symptoms of the diagnosis. When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? Assist in completing an application for admission. Supply the client with written information about his or her mental illness. Provide an opportunity for the family to discuss why they felt the admission was needed. The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? Exploring the client's ability to function Exploring the clicnt's potential for self-harm. ane about the client's camel or vane of why the rescue was unsuccessful. A client says to the nurse, "The federal guards were sent to kill me.” Which is the best response by the nurse to the client's concern? I don't believe this is true." The guards arc not out to kill you." Se rr een eter anr rete "What makes you think the guards were sent to hurt you?" A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? Move the client next to the nurses’ station. Keep the television and a soft light on during the night. Play soft music during the night, and maintain a well-lit room. A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? Encouraging quiet reading and writing for the first few days. Identification of physical activities that will provide exercise No socializing activities, until the client asks to participate in milieu When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? Suppressing feelings of anxiety Continuing contact with a crisis counselor. Eliminating all anxiety from daily situations A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? Borderline. Schizotypal. Obsessive-compulsive The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? Asking the client to leave the group session. Asking another nurse to escort the client out of the group session. Telling the client that they will not be able to attend any future group sessions A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult? Psychosis. Repression. Dissociative disorder A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? Place the client in seclusion for 30 minutes. 1. 2. Tell the client that the behavior is inappropriate. 3. ee eee on een 4. Tell the client that their telephone privileges are revoked for 24 hours. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 3. Ping pong 4. Basketball The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home. Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. 2. a. 4. Provide stimulation in the environment. 5. 6. Maintain NPO (nothing by mouth) status The nurse determines that the wife of an alccoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? w 2. “My attendance at the meetings has helped me to see that | provoke my husband’s violence.” 3. “| enjoy attending the meetings because they get me out of the house and away from my husband.” 4. “Il can tolerate my husband’s destructive behaviors now that | know they are common among alcoholics. A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. | have to go. | don't want any more treatment. | have things that | have to do right away.” The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1, Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the health care provider (HCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. 1, Dental decay 2. Moist, oily skin 3. Loss of tooth enamel 5. Body weight well below ideal range The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately. 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program. 4, Tell the client that she is not allowed to exercise rigorously. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2- bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. Aclient who thrives on managing others 4, A client who could benefit from the client’s assistance at mealtime The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse ta the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. “With whom do you live?” 2. “Who is available to help you?” 3, “What leads you to seek help now?” 4. “What do you usually do to feel better? A2 The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. Acrisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. cvone may not conte aca foranoter ene ns STN BOER ore The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 1. Signs of depression 2. Reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission A depressed client on an inpatient unit says to the nurse, “My family would be better off without me.” Which is the nurse's best response? 1. “Have you talked to your family about this?” 2. “Every one feels this way when they are depressed.” 3. “You will feel better once your medication begins to work.” The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. 1. Initiate confinement measures. 2, Acknowledge the client’s behavior. 3, Assist the client to an area that is quiet. 5. Allow the client to take control of the situation Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1 The adolescont gives awaya DVD anda cherished avtoyaphed picture of 2. The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client’s clothes without asking. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication 2. Allowing increased “in-room” activities 3, Increasing the level of suicide precautions 4, Allowing the client off-unit privileges as needed The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1, Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4, Explaining the importance of leaving the violent situation A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels “as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? 1. “You need to try to be realistic. The rape did not just occur.” 2. “It will take some time to get over these feelings about your rape.” The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? 1, Use of confabulation 2. Improvement in sleeping 3. Absence of sundown syndrome 4. Presence of personal hygienic care The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3, Observing rigid rules and regulations 4. Having the need always to make the right decision A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. | can't do anything right." How should the nurse plan to respond to the client's statement? Reassure the client that things will get better. 1. 2. Tell the client that this is not true and that we all have a purpose in life. 4, Remain with the client and sit in silence; this will encourage the client to verbalize feelings. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, “This is all my health care provider's fault. | have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1. Anexpected coping mechanism 2. An ineffective defense mechanism 3. A need to notify the hospital lawyer 4, An expression of guilt on the part of the client A client experiencing a great deal of stress and anxiety is being taught to use self- control therapy. Which statement by the client indicates a need for further teaching about the therapy? "This form of therapy can be applied to new situations.” "An advantage of this technique is that change is likely to last.” "Talking to oneself is a basic component of this form of therapy.” 1. 2. 3. 4 The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 2; Display an attitude of detachment, confrontation, and efficiency. 3. Demonstrate confidence in the client's ability to deal with stressors. 4. Provide hope and reassurance that the problems will resolve themselves. A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques. 2 Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4 Place the client in a quiet room alone to decrease stimulation. The nurse is developing a plan of care for a client who was experiencing anxiety after the lass of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1. Anxiety 2. Unrealistic outlook 2, Lack of ability to cope effectively 4, Disturbances in thoughts and ideas A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy? "It uses positive reinforcement.” 1. 3. “It increases social behaviors in the client.” 4, “It increases the level of self-care in the client." The nurse is performing an admission assessment on a client at high risk for suicide. Which assessment question will best elicit data related to this risk? “What are you feeling right now?" “How many times have you attempted suicide in the past?” & Ww Po “Why were your attempts at suicide unsuccessful in the past?” The nurse in the mental health unit is performing an assessment in a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? Depression Schizophrenia Obsessive-compulsive disorder BRwn oa The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, “I'm feeling much better now, and I'm ready to go straight.” Which response by the nurse would be therapeutic? "You have said this many times before!" 2. "Tell me what makes you feel that you are ready.” 3. "| need to see changes in you to believe that you are ready to go straight.” 4. “I'm so glad to hear you talking this way. | will let your health care provider know.” A client diagnosed with depression shares with the outclinic nurse, “I lost my job this week and can't pay my rent. My daughter is my only family, but | don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern? “Let's talk about the circumstances that caused you to lose your 1. job." 2. “There are homeless shelters available for people who are experiencing this exact situation.” 4. “Being homeless would allow us to admit you to the hospital so you will have a place to eat and sleep.” "Your comment is really inappropriate.” “Thank you, the perfume was a gift.” “Neither my hair nor my perfume is the focus of today’s session.” | eee Rwn a The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client? "You look lovely today.” “Don't worry; everyone gets depressed once in a while.” Rwna “You will feel better when your medication starts to work.” Which activity should the nurse include in the plan of care for a client who is experiencing psychomotor agitation? Playing checkers with members of the staff Reading in a quiet, low-stimulus environment Engaging in a card game with other clients on the unit Rwn os | The nurse is preparing a client for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. ABs e Administer tap water enemas. Avoid discussing the procedure. A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2. Cholesterol level 3. Blood urea nitrogen Before giving the client the initial dose of disulfiram, what should the psychiatric home health nurse determine? ty If there is a history of hyperthyroidism 2, When the last full meal was consumed 3. If there is a history of diabetes insipidus The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis? “lL couldn't touch a public doorknob unless | wore gloves.” ids 3. “Just the thought of getting into an elevator causes me to panic.” 4. “Speaking to more than one or two people would be impossible for me." A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement describes the nurse's obligation to the client? Arrange for the client go to the local mental health center daily for 1. counseling. 2. Ask the client's permission to reveal the suicidal plans to the health care provider (HCP). 3. Assure the client that the confidence between nurse and client will be strictly adhered to. Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1. 2. The community's opposition to outpatient mental health clinics 3. The associated increased risk that the client may become homeless 4. The family's negative reaction to transferring the client to community-based care During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia Refusing to eat and excessive exercising Eating only vegetables and fruits and fasting Hoarding of food and difficulty controlling food intake di 2 3 4 | 
