CH. 10,11,12,13 Flashcards
(219 cards)
1
Q
A nurse on a mental health unit is caring for a client who is displaying signs of anger. Which of the following pieces of information about the client is the strongest indicator that the client might become aggressive?
A. The client has marginal coping skills
B. The client has a history of violence
C. The client feels powerless after being hospitalized
D. The client blames others for her problems
A
B
2
Q
A nurse is caring for a client in a mental health facility and overhears the client discussing plans to harm her father-in-law physically when she is discharged. Which of the following interventions should the nurse take?
A. Ask the client to sign a contract agreeing not to harm others
B. Notify the provider of the client’s threat
C. Keep the client’s discussion confidential
D. Place the client in individual observation
A
B
3
Q
A nurse is contributing to the plan of care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse recommend?
A. Search the client and his belongings upon arrival
B. Assign the client to a private room near the nurse’s station
C. Instruct assistive personnel to check on the client every 15 m in
D. Keep the door to the client’s room closed
A
A
4
Q
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for venlafaxine. Which of the following statements should the nurse make?
A. “This medication is only for short-term use”
B. “This medication can be taken on an as-needed basis.”
C. “This medication will effectively reduce your physical manifestations of anxiety.”
D. “This medication should not be stopped abruptly.”
A
D
5
Q
A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse recognize as an erotomaniac delusion?
A. “My coworker is trying to poison me because he is afraid I’ll take his job.”
B. “I have only met Jenny twice, but I know she’ll love me.”
C. “I am selling my house before the earthquake hits in May.”
D. “The foil on my walls prevents the government from controlling me.”
A
B
6
Q
A nurse is caring for a client who is dying. The client’s son appears visibly upset when he visits. Which of the following statements should the nurse make to the client’s son?
A. “Tell me how you’re feeling about your mother’s illness.”
B. “Consider bringing a support person when you visit your mother.”
C. “It is okay to feel angry when losing someone close to you.”
D. “You should think about joining a grief support group.”
A
A
7
Q
A nurse is caring for a client who has schizophrenia and is experiencing auditory and visual hallucinations. Which of the following actions should the nurse take?
A. Ask the client what the voices are saying
B. Encourage the client to use reality testing
C. Limit the client’s exposure to noise
D. Place the client in seclusion
A
B
8
Q
A nurse is teaching with a client in the day room of an acute care mental health facility. The client accuses the nurse of being “too bossy” and states the nurse does not have the right to pressure anyone. Which of the following responses should the nurse provide?
A. “What makes you say that?”
B. “Tell me what I said that made you feel uncomfortable.”
C. “Why are you feeling pressured by me?”
D. “You shouldn’t make negative statements since I’m trying to help you.”
A
B
9
Q
A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client’s behavior?
A. Confront the client for breaking the rules
B. Stand close to the client to offer comfort and support
C. Speak to the client with clear, calm, caring statements
D. Escort the client to the nurse’s station
A
C
10
Q
A nurse is assisting with the care of a client who has a terminal illness. The client yells at the nurse, “Get out of my sight. You’ve always bothering me about something!” Which of the following responses should the nurse offer?
A. “You don’t have to yell. I’m sorry you feel like I’ve bothered you.”
B. “I’ll go, but I’ll be back in a little while when you have calmed down.”
C. “I’m going to have to ask you to be quieter since there are other clients on this unit.”
D. “I’ll be here if you would like to talk about how you feel.”
A
D
11
Q
A nurse in an acute mental health facility is assisting with the plan of care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse recommend?
A. Encourage the client to focus on personal hygiene
B. Limit the hours the client sleeps each day
C. Instruct the client to practice thought-stopping
D. Make negative statements about the client’s behavior
A
C
12
Q
A nurse is preparing to care for a client who was brought to a community health facility by her caregiver, who states that the client refuses to eat. The nurse notes the client has lost weight, avoids making eye contact, and defers questions to the caregiver. Which of the following actions should the nurse take?
A. Make sure the caregiver is present when interviewing the client
B. Document how the caregiver responds when told that the client looks neglected
C. Ask the client why she refuses to eat the caregiver’s food
D. Identify sources of stress for the caregiver
A
D
13
Q
A nurse is reinforcing teaching about stress management with a client who is experiencing anxiety. Which of the following techniques should the nurse recommend to assist the client in identifying his stressors?
A. Biofeedback
B. Intellectualization
C. Journaling
D. Cognitive reframing
A
C
14
Q
A nurse is interacting with a client who has a psychotic disorder when the client suddenly turns her head as if listening to something and says, “The boss says she is going to hit me with a stick!” Which of the following responses should the nurse offer?
A. “The boss can’t hurt you with that stick
B. “Why are you talking to yourself?”
C. “I don’t see anyone, but it sounds like you are frightened.”
D. “There isn’t anyone here but you and me, so you need to explain.”
A
C
15
Q
A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the nurse that he isn’t going to attend any further sessions and states, “I don’t have time for all that talking.” Which of the following responses should the nurse provide?
A. “It must be difficult for you to talk about family problems.”
B. “You should continue attending the family counseling sessions until the therapist tells you to stop.”
C. “If you continue to go to family counseling, I’m sure you’ll be able to resolve your family problems soon.”
D. “I think you need to continue family therapy if your partner and children want to receive further counseling.”
A
A
16
Q
A nurse is caring for a client who is having an acute panic attack. Which of the following actions should the nurse take?
A. Speak to the client in a raised voice
B. Walk the client to the dayroom
C. Use repetition when speaking with the client
D. Secure the client in his room alone
A
C
17
Q
A nurse is heling evaluate the plan of care for a client who has antisocial personality disorder. Which of the following client actions indicates that he is making progress with the treatment? (select all that apply)
A. Assisting another client who has depression to fill out a menu
B. Nominating himself to chair the client government meeting
C. Requesting a weekend pass to go home
D. Serving as the judge for a unit talent show
E. Informing the nurse that the staff provides excellent care to clients
A
A,C
18
Q
A nurse is teaching a client who has schizophrenia about involuntary commitment. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
A. “My family cannot commit me because I am homeless.”
B. “Even when I’m calm, I’ll be forced to take psychotropic medication.”
C. “At least 2 doctors must support the commitment application.”
D. “At least 2 doctors must support the commitment application.”
A
C
19
Q
A nurse is caring for a client who has social anxiety disorder. Which of the following client statements should the nurse expect?
A. “I am embarrassed to eat in public.”
B. “I often feel like I am going to have a heart attack.”
C. “I struggle to control my constant worry.”
D. “I have to step over the cracks in the sidewalk or else something bad might happen.”
A
A
20
Q
A nurse is speaking with a client whose partner was killed unexpectedly. The client states, “I just don’t know what to do now.” Which of the following actions should the nurse take?
A. Talk to the client about available community resources
B. Distract the client by discussing events not related to the crisis
C. Reassure the client that he will feel better soon
D. Give the client advice about what to do during the next few days
A
A
21
Q
A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements should the nurse make?
A. “Limit daytime napping to an hour maximum.”
B. “Watch TV as you fall asleep.”
C. “If you aren’t able to sleep, you can get out of bed and read a book.”
D. “Track the number of hours that you sleep each night.”
A
C
22
Q
A nurse is collecting fata from a client who was diagnosed with schizophrenia. The nurse should identify that which of the following findings is considered a positive symptom of schizophrenia?
A. Hallucinations
B. Social withdrawal
C. Anergia
D. Flat effect
A
A
*Positive symptoms fall into the following categories: content of thought, form of thought, perception, or sense of self. The nurse should identify that hallucinations fall under the category of perception and cause the client to experience sensory perceptions that are not associated with reality. Other positive symptoms include delusions, depersonalization, and concrete thinking
23
Q
A nurse is caring for a client who has schizophrenia and has been admitted to the mental health unit. The client has a history of aggression and has been continually pacing the hallway in an agitated manner over the past hour. Which of the following responses should the nurse make?
A. “It’s a beautiful day outside. Let’s take a walk together.”
B. “Sit down so we can try a relaxation exercise.”
C. “Would you like your antianxiety medication now?”
D. “You are pacing back and forth. Can you tell me what you are feeling?”
A
D
24
Q
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms?
A. “I just feel so hopeless.”
B. “The government has been watching my house.”
C. “I am unable to remember to brush my teeth.”
D. “I no longer enjoy the activities I used to love.”
A
C
25
A nurse in a community mental health facility is caring for a group of clients. Which of the following clients should the nurse identify as experiencing an adventitious crisis?
A. A client who has a new diagnosis of severe bipolar disorder
B. A client who is depressed following a devastating fire in her home
C. A client who is experiencing acute grief following his father's death
D. A client who is experiencing postpartum depression following the birth of her first child
B
26
A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as negative symptoms?
A. Hallucinations
B. Inability to experience pleasure
C. Disorganized speech
D. Unusual behavior
B
27
A nurse on a mental health unit is caring for a client who begins throwing objects at other clients. Which of the following actions is the priority nursing intervention?
A. Attempt to restrain the client's arms
B. Administer an anti-anxiety medication
C. Place the client in seclusion
D. Tell the client to stop the behavior
D
28
A nurse is collecting data from a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make?
A. "Please try to focus on our conversation."
B. "There is nothing over there except a chair."
C. "Tell me what you are seeing by that chair."
D. "Whatever you are seeing by chair is not real."
C
29
A nurse is reinforcing teaching with the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching?
A. "We will not set time limits for discussing her delusions."
B. "We will avoid reacting to her command hallucinations."
C. "She might lose weight due to her medications."
D. "She might be having a relapse if she stops attending social events."
D
30
A nurse is reinforcing teaching with a client who reports depression and has a new prescription for an SSRI medication. Which of the following statements should the nurse make?
A. "You should avoid foods with tyramine while taking this medication."
B. "If the adverse effects are too bothersome, stop taking the medication."
C. "Drinking alcohol is allowed with this type of medication."
D. "The effect of the medication may take several weeks to be felt."
D
31
A nurse is collecting data about the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide?
A. Jumping off a bridge
B. Inhaling carbon monoxide
C. Hanging with a rope
D. Swallowing antidepressant pills
D
32
A nurse is caring for a client who returns to the unit from day pass 2 h ours late. The client has slurred speech, and the nurse smells alcohol on the client's breath. What should the nurse say to the client in response to this situation?
A. "Why are you returning late from your day pass?"
B. "How much did you drink? You know drinking is against the rules."
C. "We will need to discuss your actions after you've had a chance to sleep."
D. "I'm disappointed that you were not more responsible while on a day pass."
C
33
A nurse is caring for a client who has tardive dyskinesia. Which of the following tools should the nurse use in performing an assessment on the client?
A. CAGE Assessment
B. Hamilton Anxiety Rating Scale
C. Abnormal Involuntary Movement Scale (AIMS)
D. SAFE-T Tool
C
34
A nurse on a mental health unit is caring for a client who has social anxiety disorder and is exhibiting signs of panic. Which of the following actions should the nurse take to reduce the client's level of anxiety?
A. Accompany the client to an area with increased environmental stimuli
B. Suggest that the client lies down and rests
C. Place the client in seclusion
D. Encourage the client to practice deep breathing
D
35
A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect?
A. Hallucinations
B. Impaired memory
C. Dysphoria
D. Social discomfort
D
36
A nurse is collecting data from a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make?
A. "I thought I hear something too."
B. "Is someone telling you something?"
C. "What are you hearing?"
D. "There is nobody in that chair for you to listen to."
C
37
A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first?
A. Assertive community treatment
B. Supportive group
C. Private counseling
D. Vocational rehabilitation services
A
38
A nurse is collecting data from a client who is at risk for cognitive impairment. Which of the following findings should the nurse identify as an early indication of cognitive decline?
A. Disorientation to time
B. Problems handling finances
C. Social withdrawal
D. Impaired recent memory
D
39
A nurse is planning care for a client who has dissociative disorder and is experiencing flashbacks while in public. Which of the following interventions should the nurse include in the plan to help the client recognize and counter the flashbacks?
A. Encourage reality testing
B. Provide opportunities for socialization
C. Consistently remind the client of past traumatic events
D. Discourage client expressions of negative feelings
Encourage reality testing
A
40
A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for this client?
A. Walking with a staff member
B. Playing ping-pong in the dayroom with another client
C. Playing basketball with other clients in the gym
D. Riding on a stationary bike alone in the fitness room
A
41
A nurse on an inpatient mental health unit is planning care for a client who was admitted following a suicide attempt. Which of the following actions should the nurse include in the plan?
A. Keep the door of the client's room to open while the client is awake
B. Ensure that the client's meal tray contains no knives
C. Observe the client swallow medications
D. Have a staff member observe the client once every 30 minutes
C
42
A nurse is caring for a client who has post-traumatic stress disorder (PTSD) and who is undergoing eye movement desensitization and reprocessing (EMDR) therapy. The nurse should identify that EMDR includes which of the following strategies?
A. Exposes the client to circumstances that trigger the PTSD
B. Assists the client with behavioral modification
C. Encourages the client to visualize a relaxing scene when traumatic memories occur
D. Uses stimuli to change how the client processes the trauma
D
43
A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client should the nurse recognize as demonstrating the defense mechanism of displacement?
A. "I smoked for years, but now I cannot stand to be around cigarette smoke."
B. "I didn't get the promotion at work because my boss hates me."
C. "My partner yelled at me, so I made the cat go outdoors."
D. "I won't worry about losing my job until my child's break from school is over."
C
44
A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take?
A. Encourage the client to attend assertive behavior sessions
B. Ensure staff members set limits on the client's behavior
C. Tell the client to socialize more with other clients on the unit
D. Frequently implement measures to increase the client's self-esteem
B
45
A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take?
A. Encourage the client to attend assertive behavior sessions
B. Ensure staff members set limits on the client's behavior
C. Tell the client to socialize more with other clients on the unit
D. Frequently implement measures to increase the client's self-esteem
b
46
A nurse is reviewing the medical history of a client who has a new prescription for electroconvulsive therapy (ECT). Which of the following findings should the nurse identify as the priority?
A. Severe depression
B. Cardiac arrhythmia
C. Bipolar disorder
D. Parkinson's disease
B
47
A nurse is leading a group therapy session for a group of clients. Which of the following client statements should indicate to the nurse that the client is using the defense mechanism of rationalization?
A. "I became a team manager because I'm not tall enough to succeed at basketball."
B. "I don't want to talk right now about the fire that destroyed my home."
C. "I take amphetamines because it's the only way I can keep up with all the studying for my classes."
D. "I will spend a day cleaning my house when I feel like my life is out of control."
C
48
A nurse is assisting with the admission of a client who has antisocial personality disorder. Which of the following findings should the nurse expect?
A. Reluctance to confide in others
B. Doubting the trustworthiness of others
C. Holding grudges against others
D. Disregarding the safety of others
D
49
A nurse is caring for a client who reports that the television set in the room is really a 2-way radio states, "Voices are coming from the TV, and everything we say in this room is being recorded." Which of the following responses should the nurse make?
A. "What we say is not being recorded."
B. "Let's ignore the voices and talk about something else."
C. "That must be very frightening."
D. "Why do you think the TV is a 2-way radio"
C
50
A nurse is working with a client who exhibits extreme superstition, elaborate speech patterns, and eccentric behavior. The nurse should identify these features as which of the following personality disorders?
A. Paranoid
B. Histrionic
C. Antisocial
D. Schizotypal
D
51
A nurse is assisting with the care of a client who has schizophrenia and is being discharge from an acute mental health setting. Which of the following should be included in the discharge plan?
A. Refer the client to respite care services
B. Provide a list of primary preventative mental health group
C. Enroll the client in a 12-step program
D. Contact an intensive outpatient program
D
52
A nurse in a provider's office is reinforcing teaching with a client who is experiencing stress due to the loss of a job. Which of the following instructions should the nurse give?
A. Drink no more than 6 cups of coffee per day
B. Exercise for 140 minutes each week
C. Get 6 hours of sleep every night
D. Sleep 30 minutes later each morning
B
53
A nurse is collecting data from a client who is receiving disulfiram for alcohol aversion therapy. The client is experiencing palpitations and reports nausea, a headache, and extreme thirst. The nurse should identify that which of the following situations is occurring?
A. The client is experiencing mild acetaldehyde syndrome
B. The client is having delirium tremens
C. The client is experiencing disulfiram toxicity
D. The client is not having a therapeutic response to disulfiram
A
54
A nurse is caring for a client who has schizophrenia and states, "My doctor is trying to kill me." Which of the following responses should the nurse make?
A. "Why would you say that your doctor is trying to kill you?"
B. "It must be frightening to feel that your doctor is trying to kill you."
C. "You doctors wants to help you, not kill you."
D. "How long has your doctor been trying to kill you."
B
55
A nurse is reinforcing teaching with a client who has major depressive disorder and is scheduled to begin electroconvulsive therapy (ECT). Which of the following pieces of information should the nurse include?
A. "If you're trying a benzodiazepine medication, you should take it before the procedure."
B. "You can expect to wake up about 15 minutes after the procedure."
C. "After the first procedure, you should expect to have ECT sessions monthly for a year."
D. "ECT is the primary treatment for most clients who have depression."
B
56
A nurse is caring for a client who is receiving cognitive-behavioral therapy. The client tells the nurse, "Nothing good ever happened during my marriage." When using cognitive reframing, which of the following responses should the nurse provide?
A. "Let's discuss what you considered to be negative about your marriage."
B. "What activities do you enjoy that take your mind off your marriage experience?"
C. "What did you learn from your marriage to help you in the future?"
D. "Only you can understand how your marriage negatively affected your life."
C
57
A nurse on a mental health unit is receiving reports about a group of clients. Which of the following client statements is an example of a persecutory delusion?
A. "I am the mayor of this town."
B. "My doctor is in love with me."
C. "That other nurse is trying to poison me."
D. "The end of the world is coming tonight."
C
58
A nurse is observing a client who has schizophrenia. The client is in the dayroom when another client asks him if 2 items of clothing match. He replies, "A match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on." The nurse should identify these statements as which of the following speech alterations?
A. Clang association
B. Echolalia
C. Word salad
D. Associative looseness
D
59
A nurse is caring for a client who has schizophrenia. The client states, "I like to play ball. Walk down the hall. Be careful; don't fall." The nurse should identify that the client is using which of the following patterns?
A. Pressure speech
B. Circumstantial speech
C. Clang association
D. Flight of ideas
C
60
A nurse in a provider's office is documenting the results of a general survey of a client who is new to the practice. The client reports an inability to find pleasure in any activities she previously enjoyed. Which of the following terms should the nurse use to describe the client's mood?
A. Anergia
B. Flat effect
C. Apathy
D. Anhedonia
D
61
A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make?
A. "Can you tell my why you do not want to participate in the planned group activity?"
B. "Do you understand that psychotropic medications cause weight gain?"
C. "The aerobics class will be more effective at burning calories than walking."
D. "It sounds like you have come up with an alternative exercise that works for you."
"It sounds like you have come up with an alternative exercise that works for you."
*The nurse is using therapeutic techniques of acceptance, giving recognition, and encouragement by supporting the client's idea of a way to exercise
62
A nurse is caring for a client who has schizophrenia. Which of the following client statements indicates clang associations?
A. "I am the king, and everyone should bow to me."
B. "I'm feeling schmoolizious today."
C. "Option, contrary, moose, allergic."
D. "Basketball in the hall very tall.
D
63
A nurse on an acute mental health unit is collecting data from a client who has obsessive-compulsive disorder (OCD). Which of the following behaviors should the nurse expect?
A. Being intentionally dishonest
B. Jumping rapidly between topics of conversation
C. Tapping the 4 sides of a light switch
D. Mimicking the movements of another person
C
64
A nurse in a mental health clinic is caring for a client who has anxiety disorder related to post-traumatic stress disorder (PTSD). Which of the following actions by the client indicates a therapeutic response to treatment?
A. The client spends most of the day in bed
B. The client prefers to talk about things other than his anxiety
C. The client seeks out environments with increased stimuli
D. The client identifies situations that cause anxiousness
D
65
A nurse is collecting data from a client who has schizophrenia and was recently admitted to acute care. Which of the following findings should the nurse expect?
A. Seductive behaviors
B. Obsession with rituals
C. Uncontrolled appetite
D. Associative looseness
D
66
A nurse is assisting with the admission of 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?
A. Relief about finally receiving care for a problem for which was previously afraid to ask for
B. Anger with the nursing staff for hospitalizing him against his will
C. Withdrawal from others due to shame over his recent actions
D. Remorse for stealing and destroying the car
B
67
A nurse is reinforcing teaching with a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should reinforce with the client that TMS can cause which of the following adverse effects?
A. Retrograde amnesia
B. Seizures
C. Confusion
D. Suicidal ideation
B
68
A nurse is caring for a client who has generalized anxiety disorder (GAD). Which of the following goals should the nurse include in the discharge plan of care for this client?
A. Use whistling or singing as a distraction to control hallucinations
B. Make independent decisions about daily events
C. Verbalize a realistic perception of personal appearance
D. Decrease the use of ritualistic behavior
B
69
A nurse in a provider's office is collecting data from a client who has obsessive-compulsive disorder (OCD). Which of the following prescriptions should the nurse expect the client to receive?
A. Donepezil
B. Venlafaxine
C. Buproprion
D. Sertraline
D
70
A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die." The client is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurse's priority?
A. Obtain a prescription for PRN medication for agitation
B. Attempt to reduce environmental stimuli
C. Request a prescription for physical restraints
D. Place the client in seclusion
B
71
A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die." The client is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurse's priority?
A. Obtain a prescription for PRN medication for agitation
B. Attempt to reduce environmental stimuli
C. Request a prescription for physical restraints
D. Place the client in seclusion
C
72
A nurse is collecting data from a client who was in a motor-vehicle crash that killed her sibling. The client is shaking and asks, "What can I do now?" Which of the following questions is the nurse's priority?
A. "Are you thinking about hurting yourself?"
B. "Do you have someone who could come here to be with you?"
C. "How will this situation affect your life?"
D. "What qualities have helped you cope with a crisis in the past?"
A
73
A nurse is reinforcing teaching with a client who has an anxiety disorder about nonpharmacological ways to promote good sleep habits. Which of the following recommendations should the nurse make?
A. "Schedule 20 minutes of aerobic exercise during the hour before bedtime."
B. "Eliminate all caffeinated beverages from your diet."
C. "Sleep for extra time when you can."
D. "Eat a light snack containing carbohydrates before bedtime."
D
74
A nurse is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?
A. Address the client in a high pitched voice
B. Speak to the client firmly and authoritatively
C. Remove potentially harmful objects before leaving the client alone in the room
D. Offer the client low-calorie or no-calorie fluids
B
75
A nurse is assisting with the admission of a client who reports hearing voices telling him what to do. Which of the following actions should the nurse take?
A. Instruct the client to sit in a quiet place when he hears voices
B. Ask the client to repeat what the voices are saying
C. Tell the client that the voices do not exist
D. Provide therapeutic touch when the client seems anxious
B
76
A nurse is collecting data from a client who has brief psychotic disorder. Which of the following manifestations should the nurse expect?
A. Evidence of self-mutilation
B. Suicidal threats
C. Disorganized speech
D. Report of chronic depression
c
77
A nurse is assisting with the plan of care for a client who is scheduled for electroconvulsive therapy (ECT). Which of the following interventions should the nurse add to the plan of care for this client?
A. Maintain a clear liquid diet for 6 to hours prior to ECT
B. Allow the client to sleep for 3 to 4 hours following ECT
C. Administer IM epinephrine to the client prior to ECT
D. Reorient the client to the environment after ECT
D
78
A nurse is collecting data from a client who has generalized anxiety disorder (GAD). Which of the following findings should the nurse expect?
A. Restlessness
B. Choking sensations
C. Paresthesias
D. Excessive sleepiness
A
79
A nurse on a mental health unit is caring for a client who asks the nurse out to dinner. Which of the following responses should the nurse provide?
A. "You should ask one of the other client if they'd like to go to dinner with you."
B. "Why are you asking me out to dinner?"
C. "We have a professional relationship, not a personal relationship."
D. "We should discuss this some other time."
C
80
A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion?
A. "A tornado is going to wipe us all out in 9 days."
B. "My brain is dead, and my body is slowly rotting away."
C. "The government is after me because I know top-secret information."
D. "The TV is purposely playing commercials for things I don't like."
C
81
A nurse is collecting data from a client who has schizophrenia. The client suddenly states, "I'm blue, so are you, and I'm leaving on a choo, choo, choo!" The nurse should identify the client's statement as which of the following speech patterns?
A. Clang association
B. Word salad
C. Neologism
D. Echolalia
A
82
A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association?
A. "Her mannerologies are poor."
B. "My dog blank a boa to supreme heights."
C. "I can play the flute while wearing a suit. You are cute."
D. "My joints ache. My friend is in the joint."
C
83
A nurse is collecting data on a client who antisocial personality disorder. Which of the following manifestations should the nurse expect in the client's personality?
A. Unconcerned about obeying the law
B. Suspicious of others
C. Unsociable with peers
D. Requires excessive admiration
A
84
A nurse is caring for a client with schizophrenia who started taking a first-generation antipsychotic medication 3 weeks ago. The client reports a feeling of inner restlessness, rocks back and forth when sitting down, and paces frequently. The nurse should identify that the client is experiencing which of the following adverse effects of antipsychotic medications?
A. Neuroleptic malignant syndrome
B. Akathisia
C. Anticholinergic toxicity
D. Opisthotonos
B
85
A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The client states, "This medication isn't working. I want to stop taking it." Which of the following responses should the nurse make?
A. "It is best to discontinue the medication slowly over 1 or 2 months."
B. "If the medication hasn't helped you in 3 months, it's not going to."
C. "You will likely gain weight if you stop taking the medication."
D. "This medication is the only treatment for your condition."
A
86
A nurse is assisting with the admission of a client who has schizophrenia. During the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia?
A. Anhedonia
B. Avolition
C. Flat affect
D. Hallucinations
D
87
A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the client's risk of which of the following adverse effects?
A. Increased intracranial pressure
B. Serotonin syndrome
C. Acute kidney injury
D. Hypertensive crisis
B
88
A nurse is caring for a client who has obsessive-compulsive disorder and feels that pacing the floor for a specific number of times is necessary or else "something bad will happen." Which of the following responses should the nurse provide?
A. "Nothing terrible is going to happen to you. Please stop this behavior."
B. "Are you seeking attention with this behavior?"
C. "It may help if we talked about why you find it necessary to pace the floor."
D. "Are you pacing to work off excess energy?"
C
89
A nurse is caring for a client who has bipolar disorder and is experiencing hypomania. During a conversation with other clients, she becomes agitated and begins speaking in a loud, angry voice. Which of the following actions should the nurse take?
A. Invite the client to take a walk
B. Reprimand the client for her rude behavior
C. Point out inappropriate behaviors to the client
D. Administer trazodone to the client
A
90
A nurse in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse, "Can I vote in the upcoming presidential election?" Which of the following responses should the nurse make?
A. "Why do you want to vote while you are in the hospital?"
B. "I wouldn't worry about voting right now."
C. "We can work together to find out how you can get a mail-in ballot."
D. "You'll have a lot more opportunities to vote after you get better."
C
91
A nurse is collecting data from a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms?
A. Positive
B. Cognitive
C. Negative
D. Affective
A
92
A nurse is collecting data from a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms?
A. Positive
B. Cognitive
C. Negative
D. Affective
A?
93
A nurse is reinforcing teaching with a client who has generalized anxiety disorder to perform a deep-breathing exercise. Which of the following actions should the nurse instruct the client to take?
A. Utilize chest breathing
B. Breathe in through the nose
C. Keep the shoulder erect
D. Repeat the exercise for at least 10 minutes for effectiveness
B
94
A nurse is caring for a client who is showing evidence of addiction to pain medication prescribed for rheumatoid arthritis. When questioned about the usage of the medication, the client states, "It is not an illegal drug." Which of the following defense mechanisms is the client using?
A. Displacement
B. Rationalization
C. Projection
D. Sublimation
B
95
A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take?
A. Administer oxygen
B. Administer an anticonvulsant
C. Administer an opioid antagonist
D. Administer IV fluids
A
96
A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take?
A. Administer oxygen
B. Administer an anticonvulsant
C. Administer an opioid antagonist
D. Administer IV fluids
A
97
A nurse is planning care for a newly admitted client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse recommend for this client?
A. Rotate staff assignments for the client
B. Refrain from discussing the client's maladaptive coping strategies
C. Wait for the client to initiate interactions with staff members
D. Encourage the client to participate in group therapy
D
98
A client who has cognitive impairment tells the nurse, "I'm leaving now. I have to be home by 5:00 PM because dinner will be ready." Which of the following responses by the nurse demonstrates the use of validation therapy?
A. "It it 5:30 PM now. You are in the hospital and we will bring you dinner soon."
B. "Don't worry about dinner. Your father is bringing dinner here for you tonight."
C. "At home, you had dinner at 5:00 PM. Was your father a good cook?"
D. "Your father was born around the year 1920. Can you tell me what year it is now?"
c
99
A nurse is caring for a client who has anxiety disorder. The client states that she forgot her partner's birthday after they had an argument. The nurse recognizes this action as which of the following defense mechanisms?
A. Repression
B. Splitting
C. Conversion
D. Projection
A
100
A nurse is reinforcing teaching with a client who is scheduled for electroconvulsive therapy (ECT) to treat major depression. Which of the following pieces of information should the nurse include?
A. "You will be awake during the procedure."
B. "You will experience a seizure during this procedure."
C. "You can't eat or drink anything for 24 hours before the procedure."
D. "You are not required to sign an informed consent form for this procedure."
B
101
A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions is the nurse's priority?
A. Ask the client what the voices are saying
B. Focus the client's attention on reality-based activities
C. Make eye contact when speaking with the client
D. Encourage the client to listen to music through headphones
A
102
A nurse is admitting a client who has derealization disorder. Which of the following manifestations should the nurse expect?
A. The inability to recall important personal information
B. The feeling that the surroundings are unreal
C. The inability to recall identity
D. The presence of at least 2 distinct personalities
B
103
A nurse is reinforcing teaching with the family of a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements made by a family member indicates an understanding of ECT?
A. "We are so glad there are no physical side effects of shock treatment."
B. "Thank goodness there is no permanent memory loss."
C. "Cardiac dysrhythmias can persist for several weeks."
D. "We won't be alarmed if there is some confusion after the treatment."
D
104
A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse take first?
A. Apply mechanical restraints to the client
B. Administer PRN haloperidol IM to the client
C. Approach the client in a nonthreatening manner
D. Place the client in seclusion
C
105
A nurse is caring for a client who has schizophrenia and is becoming anxious due to auditory hallucinations. Which of the following actions should the nurse take?
A. Offer the client therapeutic touch
B. Ask the client what he is hearing
C. Affirm the presence of the voices
D. Move the client into a more stimulating environment
B
106
A nurse is speaking with parents who are at a clinic for a 2-week follow-up visit after the birth of their second child. They report that their 5-year-old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the parents that this is expected behavior and illustrates which of the following defense mechanisms?
A. Compensation
B. Repression
C. Regression
D. Suppression
C
107
A nurse is speaking with parents who are at a clinic for a 2-week follow-up visit after the birth of their second child. They report that their 5-year-old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the parents that this is expected behavior and illustrates which of the following defense mechanisms?
A. Compensation
B. Repression
C. Regression
D. Suppression
C
108
A nurse in a long-term mental health facility is caring for a client who has a personality disorder. Because the client has broken a unit rule, phone privileges are being revoked. The client asks the nurse, "Can't I just make another phone call?" Which of the following responses should the nurse make?
A. "No, you can't. Go sit in your room."
B. "Okay, if you promise to obey the rules for the rest of the day."
C. "No, you can't. You have broken the rules that apply to everyone."
D. "You can make only a 5-minute phone call."
C
109
A nurse in a community urgent care facility is helping plan interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching?
A. Determine if the client is experiencing thoughts of self-harm
B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available
C. Encourage the client to shower before undergoing a physical examination
D. Assess the client for the presence of a maturational crisis
A
110
A nurse is talking with a client who has anxiety disorder. The client states, "I have something important to tell you, but you have to promise to keep it a secret." Which of the following responses should the nurse make?
A. "Anything you tell me is kept private between us."
B. "I feel uncomfortable being asked to keep a secret for you."
C. "Why do you feel that the information needs to be kept private?"
D. "I might have to share the information with your provider."
D
111
A nurse is caring for a client who has schizophrenia. The client states, "Aliens came into my room last night and took a sample of my blood." Which of the following responses should the nurse make?
A. "Aliens do not exist."
B. "Has your daughter had her baby?"
C. "Do you mean to say a laboratory technician drew your blood last night?"
D. "That does not sound real."
D
112
A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. These manifestations indicate which of the following adverse effects of haloperidol?
A. Akathisia
B. Acute dystonia
C. Tardive dyskinesia
D. Pseudoparkinsonism
C
113
A nurse is caring for a client who has generalized anxiety disorder. The client states, "I am so stressed about my work and finances. I can't think straight anymore." Which of the following actions should the nurse take first?
A. Administer antianxiety medication
B. Speak slowly and calmly
C. Remain with the client
D. Ask the client to talk about preceding events
C
114
A nurse in a mental health facility is assisting with the care of a client who has antisocial personality disorder. Which of the following behaviors should the nurse expect the client to exhibit?
A. Lack of remorse
B. Self-mutilation
C. Delusional behavior
D. Splitting
A. Lack of remorse
*A client who has antisocial personality disorder lacks empathy for others and shows no remorse of guilt for callous behavior
115
```
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms?
A. Reaction formation
B. Denial
C. Displacement
D. Sublimination
```
B
116
```
A nurse is providing preoperative teaching for a client who was providing preoperative teaching for a client who informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic
```
B
117
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply)
A. Reassure the client that everything will be okay.
B. Discuss prior use of coping mechanisms with the client.
C. Ignore the client's anxiety so that she will not be embarrassed.
D. Demonstrate a calm manner while using simple and clear directions.
E. Gather information from the client using closed-ended questions.
B,D
118
A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion?
A. Excessive stressors cause the client to experience distress.
B. The body's initial adaptive response to stress is denial.
C. Absence of stressors results in homeostasis.
D. Negative, rather than positive, stressors produce a biological response.
A
119
```
A nurse is discussing acute vs prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply).
A. Chronic pain
B. Depressed immune system
C. Increased blood pressure
D. Panic attacks
E. Unhappiness
```
B,C,E
120
A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?
A. "Cognitive reframing will help me change my irrational thoughts to something positive."
B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate."
C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety."
D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."
A
121
A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation?
A. Learn to practice mindfulness.
B. Use assertiveness techniques.
C. Exercise regularly.
D. Rely on the support of a close friend.
B
122
A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish other's work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker indicates understanding?
A. "You really should complete your own work. I don't think it's right to expect me to complete your responsibilities."
B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities."
C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor."
D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."
D
123
A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy?
A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks."
B. "The therapist will focus on my past relationships during our sessions."
C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors."
D. "This therapy will address my conscious feelings about stressful experiences."
B
124
A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique?
A. "I will write down my dreams as soon as I wake up."
B. "I may begin to associate my therapist with important people in my life."
C. "I can learn to express myself in a nonaggressive manner."
D. "I should say the first thing that comes to my mind."
d
125
A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following are appropriate to include in the plan of care? (Select all that apply.)
```
A. Priority restructuring
B. Monitoring thoughts
C. Diaphragmatic breathing
D. Journal keeping
E. Meditation
```
ABD
126
A nurse is caring for a client who has a new prescription for disulfiram (Antabuse) for the treatment of his alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. This form of treatment is an example of which of the following?
A. Aversion therapy
B. Flooding
C. Biofeedback
D. Dialectical behavior therapy
A
127
A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following is appropriate when implementing this form of therapy?
A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior.
B. Advise the client to say "stop" out loud every time he begins to feel an anxiety response related to an elevator.
C. Gradually expose the client to an elevator while practicing relaxation techniques.
D. Stay with the client in an elevator until his anxiety response diminishes.
C
128
A nurse is providing teaching for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?
A. "It is common to treat depression with ECT before trying medications."
B. "I can have my depression cured if I receive a series of ECT treatments."
C. "I will have seizures lasting 1 1/2 to 2 minutes during ECT."
D. "I will receive a muscle relaxant to protect me from injury during ECT."
D
129
A charge nurse is discussing transcranial magnetic stimulation (TMS) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
A. "TMS is indicated for clients whose depression is not relieved by medication."
B. "I will provide postanesthesia care following TMS."
C. "TMS is usually performed as an outpatient procedure."
D. "I will schedule the client for daily TMS treatments for the first several weeks."
B
130
```
A nurse is assessing a client immediately following an electroconvulsive therapy (ECT) proceedure. Which of the following are expected findings? (SATA)
A. Hypotension
B. Paralytic ileus
C. Memory loss
D. Nausea
E. Confusion
```
CDE
131
A nurse is leading a peer group discussion about the indications for electroconvulsive therapy (ECT). Which of the following is appropriate to include in the discussion?
A. Borderline personality disorder
B. Acute withdrawal related to substance use disorder
C. Bipolar disorder with rapid cycling
D. Dysphoric disorder
C
132
A nurse is planning care for a client following surgical implantation of a vagus nerve stimlation (VNS) device. The nurse should plan to monitor for which of the following adverse effects? (SATA)
```
A. Voice changes
B. Seizure activity
C. Disorientation
D. Dysphagia
E. Neck pain
```
ADE
etc..
coughing, hoarseness, dyspnea
133
A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?
A. "ECT is the recommended initial treatment for bipolar disorder."
B. "ECT is contraindicated for clients who have suicidal ideation."
C. "ECT is effective for clients who are experiencing severe mania."
D. "ECT is prescribed to prevent the relapse of bipolar disorder."
c
134
A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following is an appropriate response by the nurse?
A. "Why do you think you feel the need to give money away?"
B. "I am here to provide care and cannot accept this from you."
C. "I can request that your case manager discuss appropriate charity options with you."
D. "You should know that giving away your money is inappropriate."
B
135
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following should the nurse include in the teaching? (SATA)
A. Use caffeine in moderation to prevent relapse.
B. Difficulty sleeping can indicate a relapse.
C. Begin taking your medications as soon as a relapse begins.
D. Participating in psychotherapy can help prevent a relapse.
E. Anhedonia is a clinical manifestation of a depressive relapse.
BDE
136
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?
a. Narcissistic behavior
b. Fear of rejection from staff
c. Attempt to reduce anxiety
d. Adverse effect of antidepressant medication
C
137
A nurse is caring for a patient who is experiencing a panic attack. Which of the following actions should the nurse take?
a. Discuss new relaxation techniques
b. Show the client how to change his behavior
c. Distract the client with a television show
d. Stay with the client and remain quiet
D
138
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? ( Select all that apply.)
a. Excessive worry for 6 months
b. Impulsive decision making
c. Delayed reflexes
d. Restlessness
e. Need for reassurance
ADE
139
A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?
a. Assessing the client's risk for self-harm
b. Instilling hope for positive outcomes
c. Encouraging the client to participate in group therapy sessions
d. Encouraging the client to participate in treatment decisions
A
140
A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make?
a. " Tell me about how you are feeling right now."
b. " You should focus on the positive things in your life to decrease your anxiety."
c. " Why do you believe you are experiencing this anxiety?"
d. " Let's discuss the medications your provider is prescribing to decrease your anxiety."
A
141
A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder. Which of the following findings should the nurse expect?
```
A. difficulty concentrating on tasks
B. Obsessive need to talk about the event
C. Negative self-image
D. Recurring nightmares
E. Diminished reflexes
```
ACD
142
A nurse is involved in a serious and prolonged mass casualty event in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (sata)
A. avoid thinking about the incident when it is over
B. take breaks during the incident for food and water
C. debrief with others following the incident
D. hold emotions in check following the incident
E. take advantage of offered counseling
BCE
143
A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect?
A. the client remembers many details about the traumatic incident
B. the client expresses heightened elation about what is happening
C. the client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred
D. the client expresses a sense of unreality about the traumatic incident
D
144
A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?
A. the client explains that her body seems to be floating above the ground
B. the client has the idea that someone is trying to kill her and steal her money
C. the client states that the furniture in the room seems to be small and far away
D. the client cannot recall anything that happened during the past 2 weeks
C
145
A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?
A. teach the client to recognize how stress brings on a personality change in the client
B. repeatedly present the client with information about past events
C. make decisions for the client regarding routine daily activities
D. work with the client on grounding techniques
D
146
A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (SATA)
A. "When did you start hearing the voices?"
B. "The voices are not real, or else we would both hear them."
C. "It must be scary to hear voices."
D. "Are the voices telling you to hurt yourself?"
E. "Why are the voices talking to only you?"
ACD
147
A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (SATA)
```
A. Auditory hallucinations
B. Lack of motivation
C. Use of clang associations
D. Delusion of persecution
E. Constantly waving arms
F. Flat affect
```
ACDE
148
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?
A. "I am a superhero and an immortal."
B. "I am no one and everyone is me."
C. "I feel monsters pinching me all over."
D. "I know that you are stealing my thoughts."
B
149
A nurse is caring for a client on acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following actions should the nurse take first?
A. Use therapeutic communication to discuss the hallucination with the client.
B. Initiative one-to-one observation of the client.
C. Focus on the client on reality.
D. Notify the provider of the client's statement.
B
150
A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take?
A. Stop the interview at this point, and resume later when the client is better able to concentrate.
B. Ask the client, "Are you seeing something on the ceiling?"
C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too."
D. Continue the interview without comment on the client's behavior.
B
151
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 a need for further teaching?
A. "I can promote my client's sense of control by establishing a schedule."
B. "Self-assessment will help me cope with emotional reactions to client care."
C. "I should practice limit-setting to help prevent client manipulation."
D. "Maintaining professional boundaries is a priority of client care."
A
152
A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?
A. "I'm scared that you're going to leave me."
B. "I'll go to group therapy if you'll let me smoke."
C. "I need to feel that everyone admires me."
D. "I sometimes feel better if I cut myself."
A
153
A charge nurse is preparing a staff education session on personality disorders. Which of the following should be included as personality characteristics associated with all of the personality disorders? (Select all that apply.)
A. Difficulty in getting along with other members of a group
B. Belief in the ability to become invisible during times of stress
C. Display of defense mechanisms when routines are changed
D. Claiming to be more important than other persons
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
ACE
154
A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms?
A. Regression
B. Splitting
C. Undoing
D. Identification
B
155
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. When assessing this client, which of the following are expected findings? (Select all that apply.)
A. Demonstrates extreme anxiety when placed in a social situation
B. Has difficulty making even simple decisions
C. Attempts to convince other clients to give him their belongings
D. Becomes agitated if his personal area is not neat and orderly
E. Blames others for his past and current problems
CE
156
```
A nurse is discussing the risk factors
for somatic symptom disorder with
a newly licensed nurse. Which of
the following risk factors should the
nurse include? (Select all that apply.)
```
```
A. Age older than 65 years
B. Anxiety disorder
C. Female gender
D. Coronary artery disease
E. Obesity
```
BC
Also, childhood trauma
157
```
2. A nurse is reviewing the medical
record of a client who has
conversion disorder. Which of
the following findings should the
nurse identify as placing the client
at risk for conversion disorder?
```
A. Death of a child 2 months ago
B. Recent weight loss of 30 lb
C. Retirement 1 year ago
D. History of migraine headaches
a
158
A nurse is assessing a client who
has illness anxiety disorder. Which
of the following findings should the
nurse expect? (Select all that apply.)
```
A. Obsessive thoughts about disease
B. History of childhood abuse
C. Avoidance of health care providers
D. Depressive disorder
E. Narcissistic personality
```
ABCD
159
A nurse is developing a plan of
care for a client who has conversion
disorder. Which of the following
actions should the nurse include?
A. Encourage the client to spend time alone in his room.
B. Monitor the client for self‐harm once per day.
C. Allow the client unlimited time to discuss physical manifestations.
D. Discuss alternative coping strategies with the client.
D
160
A nurse is counseling a client who
has factitious disorder imposed on
another. Which of the following client
statements should the nurse expect?
A. "I had to pretend I was injured in order to get disability benefits."
B. "I know that my abdominal pain is caused by a malignant tumor."
C."I needed to make my son sick so that someone else would take care of him for a while."
D."I became deaf when I heard that my husband was having an affair with my best friend."
C
161
A client diagnosed with major depressive disorder is newly prescribed sertraline (Zoloft). Which of the following teaching points would the nurse review with the client? Select all that apply.
1. Monitor the client for suicidal ideations related to depressed mood.
2. Discuss the need to take medications, even when symptoms improve.
3. Instruct the client about the risks of abruptly stopping the medication.
4. Alert the client to the risks of dry mouth, sedation, nausea, and sexual side effects.
5. Remind the client that the medication’s full effect does not occur for 4 to 6 weeks.
2345
162
A client diagnosed with antisocial personality disorder is facing a 20-year prison term. The client has been prescribed sertraline (Zoloft) for depressed mood. Which inter- vention would take priority?
1. Monitor the client for suicidal ideations related to depressed mood.
2. Discuss the need to take medications, even when symptoms improve.
3. Instruct the client about the risks of stopping the medication abruptly.
4. Remind the client that it takes 4 to 6 weeks for the medication’s full effect to occur.
1
163
A client diagnosed with major depressive disorder is prescribed bupropion (Wellbutrin) and sertraline (Zoloft). The client states, “Why am I on two antidepressants?” Which is the best nursing response?
1. “The bupropion assists the client with smoking cessation while the sertraline treats
depressive symptoms.”
2. “Sertraline assists with the negative side effects of bupropion.”
3. “The medications treat the symptoms of depression through different mechanisms
of action.”
4. “Both medications help with symptoms of anxiety along with depression.”
3
164
Regarding the etiology of schizophrenia, which of the following support(s) a biological theory? Select all that apply.
1. Dopamine hypothesis.
2. High incidence of schizophrenia after prenatal exposure to influenza.
3. Ventricular and sulci atrophy.
4. Downward drift hypothesis.
5. Increased level of serotonin.
125
165
A nurse is reviewing the chart of a client who has dissociative amnesia. Which of the following should the nurse expect?
A. The client was seriously injured while under the influence of alcohol.
B. The client has a history of panic attacks.
C. The client chose to drop out of college a few months ago.
D. The client works a stressful job at an international bank.
a
166
A nurse in a community health centers teaching families of clients who have post traumatic stress disorder about expected clinical manifestations. Which of the following manifestation should the nurse include?
Experiences feelings of isolation
167
A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorderAfter returning from military deployment. Which of the following is the priority action for the nurse to take?
Stay with a client when flashbacks occur.
168
A nurse is planning care for a client who has to undergo electroconvulsive therapy. Which of the following actions should the nurse include in the plan?
Monitor the clients cardiac rhythm during the procedure
169
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
Assist the client with deep breathing exercises.
170
A nurse in a health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others?
Command hallucinations
171
A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?
Assertive community treatment
172
A school nurse is assessing a school age child to experience the traumatic loss of a parent eight months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing posttraumatic stress disorder?
Lack of interest in the upcoming holiday
173
A Nurse is planning care for a client who has generalized anxiety disorder.Which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
Mild
174
A nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?
a) “How do you think this event is affecting your life right now?”
b) “Who do you talk to when you need help?”
c) “Are you having thoughts about harming yourself.”
d) “What do you usually do to cope with problems in your life.”
c
175
A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?
a) A client whose partner died 5 years ago still talks about him in the present tense
b) A client who states she will worry about her grade after she finishes planning a party
c) A client who has stomach pain before presenting a project to his co-workers
d) A client who states she did not get a promotion because her boss doesn’t like her
d
176
A nurse is teaching about deep-breathing exercises with a client who reports experiencing intense stress at work. Which of the following statements by the client indicates an understanding of the teaching?
a) “I will focus on the causes of my stress during the exercise.”
b) “I will inhale through my mouth and exhale through my nose.”
c) “I will hold my breath for 5 or 6 seconds each time.”
d) “I will focus on how the muscles in my stomach feel with each breath.”
D
177
A nurse is developing a behavior contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?
a) Decrease the number of verbal outbursts
b) Increased self-esteem
c) Use projection during group therapy
d) Use bargaining skills for behavior consequences
A
178
A nurse is providing discharge teaching about manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching?
A) The client develops an inability to concentrate
B) The client increases participation in social activities
C) The client exhibits an inflated sense of self
D) The client begins sleeping more than usual
A
179
A nurse is caring for a client who has schizophrenia. The client’s employer call to discuss the client’s condition. Which of the following is the appropriate nursing action?
a) Contact the facility legal department
b) Consult the client
c) Consult the client’s family
d) Contact the provider
B
180
A nurse is performing a Mental Status Examination for a client who has schizophrenia. The nurse should recognize that which of the following actions requires the client to think abstractly?
Determine the meaning of a proverb
Count by adding sevens consecutively
Explain what to do if he misses the bus
Name the last three presidents of the United States of America
a
181
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 when using thoughts stopping technique?
a) “Ask a family member to check the locks for you at night.”
b) “Keep a journal of how often you check the locks each night.”
c) “Snap a rubber band on your wrist when you think about checking the locks.”
d) “Focus on abdominal breathing whenever you go to heck on the locks.”
C
182
A nurse is providing teaching to the daughter of an older adult who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the teaching?
“I will provider my mother with detailed instructions about how to perform self-care.”
“I will limit my mother’s clothing choices when she is getting dressed.”
“I will wake my mother up a couple of times in the night to check on her.”
“I will discourage my mother from talking about her physical complaints.”
B
183
```
A nurse is caring for a client who has just returned to the unit after receiving an electroconvulsive therapy treatments. Which of the following assessments is the nurse’s priority?
Return of bowel sounds
First voiding
Short term memory
Presence of gag reflex
```
C
184
```
A nurse is caring for a client following a physical assault. The client states “i don't remember what happened to me”. The nurse should recognize that the client is using which of the following defense mechanism?
Rationalization
Repression
Denial
Displacement
```
B
185
```
A nurse in a community health facility is interviewing a client who recently lost his job. The client states “ I was fired because my boss doesn't like me”. Which of the following defense mechanisms is the client displaying?
Dissociation
Rationalization
Displacement
Repression
```
B
186
A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from the others clients. Which of the following techniques should the nurse use?
Crisis intervention to decrease anxiety
Aversion therapy to provide distraction
Systematic desensitization to extinguish the behavior
Positive reinforcement to increase desired behavior
B
187
```
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
Denial
Rationalization
Compensation
Displacement
```
D
188
A nurse is providing teaching about disorder management for a client who has PTSD. Which of the following statements should the nurse include in the teaching? Ch12 pg 64, 65
Response prevention is an effective treatment for PTSD
You should try to limit the number of hours that you sleep each day
Talking about the traumatic experience is recommended
Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD
C
189
Which of the following statements made by a client’s family indicates understanding related to the adverse reactions to electroconvulsive therapy?
“We won’t be alarmed if there is some confusion after the treatment”
“Thank goodness there is no permanent memory loss”
“Cardiac dysrhythmias may persist for several weeks”
“We are so glad there are no physical side effects to shock treatment”
A
190
A nurse is working in the emergency department is assessing a client who has generalized anxiety disorder. Which of the following actions should the nurse take first?
Instruct the client to use guided imagery
Allow the client time to express his feelings
Move the client to a quiet area
Assist the client to identify his coping skills
C
191
A nurse is caring for a client who has schizophrenia and displays severe negative symptoms of the disorder. Which of the following actions should the nurse take? P . 80 ch 15
Use medication to decrease frequency of auditory and visual hallucinations
Assist the client to identify somatic and thought broadcasting delusions
Manage the client’s loud, rambling, and incoherent communication patterns
Direct the client to perform her own daily hygiene and grooming tasks
D
192
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia (SATA)
a) Auditory Hallucinations
b) Decreased motivation
c) Delusions of grandeur
d) Impaired memory
e) Flight of ideas
ACE
193
A nurse is obtaining a health history during a client’s admission to a mental health facility. The client begins to talk on her cell phone. When the client finishes talking, she reports to the nurse, “That was the president. I leave in the morning on my new mission.” Which of the following is an appropriate response?
“Why do you think the president is calling you for a mission?”
“How long have you been having conversations with the president?”
“I think you need to talk to your provider about the mission.”
“I do not think the president will need you on this mission”
B
194
A nurse is caring for a client who has antisocial personality disorder. The client uses manipulation to gain access to a smoking area from which his access has been limited as a behavioral intervention. Which of the following is an appropriate statement by the nurse? (p.130)
“You know that manipulation is not the right thing to do”
“Let’s review the consequences of your actions”
“I can talk with the provider about decreasing your smoking restriction”
“You know you shouldn’t use the smoking area”
B
195
A nurse is discussing exercise activities with an inpatient client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and is instead requests to walk in the facility’s gym. Which of the following responses by the nurse is appropriate?
“Can you tell me why you do not want to participate in the planned group activity?”
“The aerobics class will be more effective at burning calories than walking”
“It sounds as if you have come up with an alternative exercise that works for you”
“Do you understand that psychotropic medications cause weight gain?”
C
196
```
A nurse is planning care for a client who has obsessive compulsive disorder. Which of the following recommendations should the nurse include in the client’s plan of care?
Reality orientation therapy
Operant conditioning
Thought stopping
Validation therapy
```
C
197
A nurse is planning care for a group of clients in an outpatient facility. For which of the following clients should the nurse plan to provide assistance with ADLs?
A client who is in treatment for hypomania
A client who has intense manifestations of agoraphobia
A client who has negative manifestations of schizophrenia
A client who is in treatment for alcohol use disorder
C
198
A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states “I can't stand to be touched by another person”. Which of the following response should the nurse make? Ch 11 p. 58
Why don't you like to be touched by others?
I will request that the massage therapist wear gloves during your treatment
I will tell your provider that you would like a treat other than massage
Don't worry about it. Your anxiety will lessen once the massage begins
C
199
```
A nurse is caring for a client who is showing evidence of addiction to a pain medication prescribed for rheumatoid arthritis. When questioned about the usage of the medication, the client states, “It is not a street drug.” Which of the following is the correct interpretation of the clients statement?
Sublimation
Displacement
Rationalization
Projection
```
C
200
```
A nurse is interviewing a client who has brief psychotic disorder. The nurse should expect to obtain which of the following supportive information during the interview?
Regular use of marijuana
Evidence of disorganized speech
Recent diagnosis of hypothyroidism
History of chronic depression
```
B
201
A nurse is caring for a client who is experiencing active auditory hallucination. Which of the following should the nurse take? P . 80 chapter 15
Avoid asking direct questions about the client’s experience
Tell the client her experience is not real
Convey sympathy for her client’s experience
Focus the client on reality based activities
D
202
```
A nurse on a mental health unit is caring for a client who begins throwing objects at other clients. Which of the following is the priority nursing intervention?
Attempt to restrain the client’s arms.
Place the client in seclusion
Tell the client to stop the behavior
Administer an anti-anxiety medication
```
C
203
A nurse is caring for a client who has been experiencing mild anxiety. When speaking with the client, the nurse should identify that which of the following statements indicates the client is now experiencing severe anxiety?
“I started biting my nails again.”
“I cannot seem to concentrate on my work”
“I seem to be so impatient all of the time”
“I am having feelings of dread each day”
D
204
```
A nurse is speaking with a mother who is at a clinic for a 2 week f/u visit after the birth of her second child. She tells the nurse that her 5 year old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the mother that this is expected behavior and that the child is using which of the following defense mechanism?
Regression
Compensation
Repression
Suppression
```
A
205
A nurse is receiving report before her shift on a mental health unit. Which of the following clients should the nurse assess first?
A client who is withdrawing from alcohol and is experiencing hallucinations
A client who has obsessive-compulsive disorder and whose hands are bright red with cracked skin
A client who has bipolar disorder and has been pacing all night in the hallway
A client who has major depressive disorder and has been crying for several hours
A
206
A nurse is providing care to a school-age child who has low self-esteem and manipulates his peers. Which of the following actions should the nurse take?
Implement systematic desensitization techniques.
Show conditional praise when the child achieves a task.
Set realistic, short-term goals for self-care with the child
Encourage the child to implement thought-stopping techniques
B
207
A nurse is planning care for a client who has obsessive-compulsive disorder and must repeatedly check that the doors are locked at night. Which of the following instructions should the nurse give the client when using response prevention?
“Say ‘stop’ out loud when you think about checking the locks”
“Ask a family member to check the locks at night”
“Focus on abdominal breathing whenever you go to check the locks”
“Keep a journal of how often you check the locks each night”
A
208
A nurse is caring for a client who has schizophrenia. Which of the following indicates clang associations?
“Basketball in the hall very tall”
“Option, contrary, moose, allergic.”
“I am the king and everyone should bow to me”
“I’m feeling schmoozilious today.”
A
209
```
A nurse is admitting a client who is diagnosed with antisocial personality disorder. Which of the following behaviors should the nurse expect to observe?
Splitting
Delusional behavior
Lack of remorse
Self-mutilation
```
C
210
Sertraline route
po
211
sertraline action
inhibits neuronal uptake of serotonin in the CNS, thus potentiating the activity of serotonin
212
sertraline is used for?
OCD, PTSD, social anxiety disorder, panic disorder
213
SSRI early adverse effects
nausea, diaphoresis, tremor, fatigue, drowsiness
214
SSRI later adverse effects
sexual dysfunction (impotence, delayed or absent orgasm, delayed or absent ejaculation, decreased sexual interest)
215
other SSRI adverse effect
weight gain, GI bleeding, Hyponatremia , serotonin syndrome, Bruxism (grinding and clenching of teeth, usually during sleep)
216
serotonin syndrome symptoms?
» Agitation, confusion, disorientation, difficulty concentrating, anxiety, hallucinations, hyperreflexia, incoordination, tremors, fever, diaphoresis
» Usually begins 2 to 72 hr after initiation of treatment
» Resolves when the medication is discontinued
217
withdrawal syndrome
» Nausea, sensory disturbances, anxiety,
tremor, malaise, unease
› Advise clients that, after a long period of use, the medication will be tapered slowly to avoid withdrawal syndrome.
» Minimized by tapering the medication slowly
› Advise clients not to discontinue use abruptly.
218
SSRI contraindications/Precautions
Use of MAOI antidepressants or TCAs can cause
› Educate the client about this combination. serotonin syndrome.
219
```
A nurse is caring for a client who has been taking sertraline (Zoloft) for the past 2 days. Which of the following assessment findings should alert the nurse to the possibility that the client is developing serotonin syndrome?
A. Bruising
B. Fever
C. Abdominal pain
D. Rash
```
fever
