At the first meeting of a group at a daycare center for older adults,
the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make?
A."Yes, I am the leader today. Would you like to be the leader tomorrow?"
B."Yes, I will be leading this group. What would you like to accomplish?"
C."Yes, I have been assigned to lead this group. I will be here for the next 6 weeks."
D. "Yes, I am the leader. You seem angry about not being the leader yourself."
A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take?
A. Notify the health care provider immediately and force fluids.
B. Prior to giving the next dose, notify the health care provider of these symptoms.
C. Record the symptoms and continue with medication as prescribed.
D. Hold the medication and refuse to administer additional doses.
A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. These behaviors are often associated with which condition?
A. Dissociative disorder
B. Obsessive-compulsive disorder
C. Panic disorder
D. Posttraumatic stress syndrome
During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization?
A."Sometimes I take an extra one of my pills when I hear the voices."
B."The voices are louder when I forget to take my medication. "
C."No matter what I do, I cannot make the voices go away. "
D."I just try to tell the voices to stop when they bother me. "
An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently exposes their body to other residents. Which intervention should the nurse implement?
A. Establish a one-to-one relationship to discuss the behavior.
B. Redirect the client to physically demanding activities.
C. Encourage the client to verbalize thoughts when acting out.
D. Restrict social interactions with other residents in the facility.
A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
A.Sublimation
B.Identification
C.Introjection
D.Repression
A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important?
A.Maintain a balanced diet and adequate exercise.
B.Be sure that the diet is adequate in salt intake.
C.Monitor for any changes in sleep pattern.
D.Report any unusual facial movements.
A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor?
A.Authority issues in childhood
B.Anger about being hospitalized
C.Low self-esteem
D.Phobia of food
Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first?
A.Remind the client to wear the nicotine (NicoDerm) patch.
B.Determine if the client still needs constant observation.
C.Encourage the client to attend the smoking cessation group.
D.Explain that clients on constant observation cannot smoke.
When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.)
A.Oxygen
B.Suction equipment
C.Continuous passive range-of-motion (CPM) machine
D.Crash cart
E.Chest tube drainage system
A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
A.Obtain objective data such as radiographs before reporting suspicions.
B.Confirm suspicions of abuse with the health care provider.
C.Report any case of suspected child abuse.
D.Document injuries to confirm suspected abuse.
A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements?
A.She is regressing to an earlier behavior pattern.
B.She is sublimating her anger.
C.She is projecting her feelings onto the nurse.
D.She is suppressing her fear.
A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make?
A."How can I help you? Tell me more about your problems."
B."Things probably aren't as bad as they seem right now."
C."Let's talk about what is right with your life."
D."I hear your misery, but things will get better soon."
A client who has been hospitalized for 2 weeks for paranoia complains continuously to the staff that someone is trying to steal their clothing. What is the correct action for the nurse to take based on the client's complaints?
A. Enroll the client in an exercise class to promote positive activities.
B.Place a lock on the client's closet to allay the client's concerns.
C.Promote extinction of the ideation by ignoring the client.
D.Explain to the client that these suspicions are certainly false.
A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best?
A."We aren't torturing you. These treatments are necessary to prevent a terrible infection."
B."I know these treatments must seem like torture to you, but we want to help you recover."
C."You have so much to live for, and all of your family members want you to live."
D."Would you like me to call the chaplain so that you can discuss your feelings privately?"
The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge?
A.Tries to interact with a few peers and staff
B.Reports feeling better and less depressed
C.Sits attentively with peers in group therapy
D.Easily awakens for morning medications
A client mumbles out loud whether anyone is talking to her or not and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement?
A.Respond to the client's feelings rather than the illogical thoughts
B.Identify beliefs and thoughts about what the client is experiencing.
C.Provide the client with hope that the voices will eventually go away.
D.Ask the client how she has previously managed the voices.
A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate?
A.Place the client on seizure precautions and monitor frequently.
B.Take the client's vital signs and notify the health care provider immediately.
C.Describe the symptoms to the charge nurse and document them in the client's record.
D.No action is required at this time because these are known side effects of her medications.
On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement?
A.Provide packaged foods for the client to eat.
B.Begin the client on total parenteral nutritional (TPN) therapy.
C.Provide a well-balanced liquid diet for the client.
D.No action is necessary because the client will eat when hungry.
Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.)
A.Importance of adherence to medication regimen
B.Current treatment measures for substance abuse
C.Signs and symptoms of an exacerbation
D.Prevention of criminal activity
E.Behavior modification for aggression
F.Chronic grief associated with long-term illness
On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorder?
A.Dissociative disorders
B.Personality disorders
C.Anxiety disorders
D.Psychotic disorders
A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client?
A.A 35-year-old client who recently attempted suicide.
B.A manic client who has started lithium carbonate treatment.
C.A client who is bipolar and is pacing the floor while telling jokes to everyone.
D.A paranoid client who believes that the staff is trying to poison the food.
A client who was admitted 2 days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement?
A.The treatment program is effective and the client is highly motivated.
B.Defense mechanisms are being used to decrease anxiety.
C.Manipulation is being used to achieve the client's personal goals.
D.The client has insight into his behaviors, so privileges should be given.
What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam (Serax)? (Select all that apply.)
A.Take the medication in the morning for best results.
B.Do not combine this medication with alcohol.
C.This medication is typically used for short-term treatment.
D.Stop the drug immediately if sleepiness occurs.
E.Avoid driving or operating equipment while taking this drug.
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?
A.Confront the client who tipped over the chair about the inconsiderate behavior.
B.Dismiss the other clients from the group therapy session for a 10-minute break.
C.Reinforce reality to the client on the floor and remove him to a quiet space.
D.Call a security code and medicate both clients with an antianxiety drug.
The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is Impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement?
A.Greet the client by first name during each social interaction.
B.Determine if the client is experiencing auditory hallucinations.
C.Introduce the client to peers on the unit as soon as possible.
D.Assign the client to a group about developing social skills.
A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take?
A.Have the staff escort the client to his room.
B.Tell the client that his behavior will be documented in his record.
C.Redirect the client by offering an activity such as playing card games.
D.Review the medication record for an antipsychotic drug.
A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of Confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior?
A.Move all medical equipment away from the client's bedside.
B.Allay fears by teaching the client about the causes of the disease.
C.Cluster care to allow for brief rest periods during the day.
D.Encourage visitation by the client's family members, including the client's young children.
A client is admitted with a diagnosis of depression. Which of the following characteristics is most indicative of depression?
A.Grandiose ideation
B.Self-destructive thoughts
C.Suspiciousness of others
D.Negative self-image
The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority?
A.The child will be protected from further harm.
B.The family's cultural values will be respected.
C.The parents will express regret at harming their child.
D.The parents will demonstrate an ability to care for burn wounds.
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