NURSING 309 Focus on Mental Health (GRADED A+) EXAM with answers plus rationales | 100% verified.

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NURSING 309 Focus on Mental Health (GRADED A+) EXAM with answers plus rationales 1.ID: 9476853992 A nurse overhears a hospitalized client with mania telling another client, “I’m actually a journ... alist writing an article for a magazine — I’m just posing as a person with mental illness.” How should the nurse respond? A. Ignoring the delusion B. Taking the client to a quiet room C. Supporting the client’s denial of illness D. Presenting the client with the actual situation Correct Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that the nurse does not share the client’s perceptions. All three of the other options — ignoring the delusion, taking the client to a quiet room, and supporting the client’s denial of illness — do not focus on reality, and they ignore the issue. Presenting the client with the actual situation helps orient the client to reality. Test-Taking Strategy: Use the process of elimination and your knowledge that reality orientation is the priority. The correct option illustrates a means of helping orient the client to reality. Review care of the client experiencing delusions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition – Psychosis, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 305, 318-320). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 2.ID: 9476861052 A client who is hallucinating fearfully says to the nurse, “Please tell that demon to get out.” How should the nurse respond to the client? A. “If you tell the demon to go away, it will.” B. “I’ll stay here with you until the demon leaves your room.” C. “If you return to bed, you will find that the demon will leave.” D. “I know you must be very upset by this, but I don’t see a demon.” Correct Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate the client’s experience, because this may lead to a regressive struggle with the client. Giving advice or false reassurance is incorrect because such techniques indicate that demons actually are present, which feeds into the client’s hallucination and reinforces the client’s behavior. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques, noting that the client is hallucinating. Remember that it is most important to maintain reality with the client. This will direct you to the correct option. Review communication techniques for the client who is hallucinating if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition – Psychosis, Communication References: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 25-29). St. Louis: Mosby. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 320). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 3.ID: 9476835369 The mother of a 3-year-old says, “My child hit his teddy bear after being scolded for picking the neighbors’ flowers.” Which defense mechanism was the child using? A. Projection B. Sublimation C. Displacement Correct D. Identification Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a less threatening substitute person or object to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to someone else, such as that which occurs in blaming or scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's. Test-Taking Strategy: Use the process of elimination and your knowledge regarding defense mechanisms. Focusing on the child’s behavior will direct you to the correct option. Review these defense mechanisms if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Development, Coping HESI Concepts: Developmental, Stress and Coping Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 171, 173). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 4.ID: 9476840153 A client says to the nurse, “Even though my husband and I keep telling them we don’t want to have children, our parents are pressuring us to ‘start a family.’ What should we say to them?” Which of the following responses by the nurse is therapeutic? A. “This must be very difficult for both of you.” Correct B. “Maybe you should say you can’t have children.” C. “How do you usually cope with that kind of interference?” D. “Tell them to have more children if they want them so badly.” Rationale: Childless families may elect not to have children or to postpone having them until they have established themselves occupationally or financially. Telling the client to tell the parents that the couple can’t have children is incorrect because the client is being encouraged to lie about life decisions rather than helping the parents understand the couple’s choices. Asking how they usually cope with such interference is incorrect because it indicates that the nurse is judgmental and has decided that the parents are interfering with the client and spouse. Saying, “Tell them to have more children if they want them so badly,” is incorrect because it is sarcastic and ridicules the situation over which the client has expressed concerns. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Family Dynamics Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 27). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 5.ID: 9476840163 A young adult client says, “I just can’t seem to stop snapping at my parents. I know they work hard to support me, but what do I do when they’re so overbearing?” Which responses by the nurse is therapeutic? A. “It’s important not to be rude to your parents.” B. “You need to be more patient with your parents.” C. “Snapping at your parents is childish. How could you?” D. “Have you talked to your parents about your frustrations?” E. Correct Rationale: The correct response is focused on the client’s concerns and encourages the therapeutic technique of formulating a plan of action. “It’s important not to be rude to your parents” and “You need to be more patient with your parents” are both nontherapeutic, judgmental responses that do not encourage the client to further explore her feelings and problem-solve. “Snapping at your parents is childish. How could you?” is incorrect because it is sarcastic and condescending, which is nontherapeutic. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Family Dynamics Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 29, 31). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 6.ID: 9476853973 A client says, “I have so much trouble caring for my husband’s child from his first marriage. I resent the money we have to pay for child support because we have to deprive my own child of things. How can I stop feeling this way?” Which response by the nurse is therapeutic? A. “Your child benefits from having a sibling.” B. “Have you shared your feelings with your husband?” Correct C. “You need to take a second job to give your child what you think she deserves.” D. “I wonder why you married him, knowing that he wouldn’t desert his biological child.” Rationale: Remarried individuals often encounter problems as a result of the stressors they bring into a marriage without prior discussion with the new partner. Bonding sometimes does always occur when a child is not one’s biological offspring. The correct answer is focused on the client’s feelings. “Your child benefits from having a sibling” is not facilitative. “I wonder why you married him, knowing that he wouldn’t desert his biological child” is incorrect because it prejudges the client. “You need to take a second job to give your child what you think she deserves” is not open ended, does not facilitate feelings, and gives advice. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Family Dynamics Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 27). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 7.ID: 9476861090 A client says to the nurse, “My wife retired last year from a lucrative law practice, and I’m really discouraged. I’ll be working until I die, even though I helped pay for her education.” Which response by the nurse is supportive? A. “That’s very unfair to you.” B. “You sound very troubled by this.” Correct C. “That’s such a tough break for you.” D. “Why not ask your wife for some help?” Rationale: Saying that the situation is unfair is judgmental and does not encourage the client to express his feelings; nor does “That’s such a tough break for you.” Suggesting that the husband approach the spouse for help is incorrect because it prematurely gives advice, a nontherapeutic communication technique. The correct option is focused on the client’s feelings. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Family Dynamics Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 124-125). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 8.ID: 9476861043 A gay man is brought to the emergency department by the police. The client tells the nurse, “I was beaten up. I guess I just have to expect this kind of treatment for the rest of my life.” Which statement by the nurse is therapeutic? A. “I think you should take some self-defense classes.” B. “Maybe you should be more discreet when you’re in public.” C. “You feel that being beaten up goes along with being gay?” Correct D. “Why not try counseling to change your sexual orientation?” Rationale: Many lesbians and gays encounter harassment or violence in the course of their lives. “I think you should take some self-defense classes” is incorrect because it advises the client, and giving advice is not therapeutic. “Maybe you should be more discreet when you’re in public” also gives advice and presumes that the client has been indiscreet. “Why not try counseling to change your sexual orientation?” is incorrect because it assumes that sexual orientation can or should be changed. The correct option indicates reflection and is focused on the client’s feelings. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Interpersonal Violence HESI Concepts: Communication, Violence Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 515). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 9.ID: 9476853957 A client whose spouse recently died is experiencing dysfunctional grieving. Which intervention has priority in the plan of care? A. Monitoring the client’s sleep pattern B. Assessing the client’s risk for violence toward self and others Correct C. Collaborating with the healthcare provider to prescribe an antidepressant D. Helping the client resolve the grief through emotional, cognitive, and behavioral means Rationale: The priority intervention for a client with dysfunctional grieving is assessment of the client’s risk for violence toward self and others. Although the nurse will assist the client in resolving the grief and monitor the client’s sleep pattern, these are not the priority interventions of the options given. Obtaining a prescription for an antidepressant is not a priority. Test-Taking Strategy: Use the process of elimination and the steps of the nursing process. Assessing the client’s risk for violence toward self and others and monitoring the client’s sleep pattern are both forms of assessment. To select from the remaining options, select assessing the client’s risk for violence toward self and others because it addresses the safety of the client. Review interventions for a client experiencing dysfunctional grieving if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Coping, Interpersonal Violence HESI Concepts: Grief and Loss, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 488-489). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 10.ID: 9476848561 A nurse develops a plan of care for a client in whom AIDS was recently diagnosed. The client is experiencing difficulty adjusting to the illness. Which interventions are appropriate for this client? Select all that apply. A. Assisting the client in verbalizing fears Correct B. Helping the client identify sources of hope Correct C. Monitoring the client for signs of self-harm Correct D. Assisting the client with problem-solving and decision-making Correct E. Discouraging social networking to prevent the spread of infection Rationale: Assisting the client with problem-solving and decision-making, helping the client verbalize fears, helping the client identify sources of hope, and monitoring the client for signs of self-harm are all appropriate interventions. In planning care for a client having difficulty adjusting to an illness, the nurse develops interventions to promote social networking that will provide needed support and information to the client. Test-Taking Strategy: Use the process of elimination and note that the client is having difficulty adjusting to a serious illness. Recall that social support is important. Review interventions for a client having difficulty adjusting to an illness if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Anxiety, Coping HESI Concepts: Mood and Affect – Anxiety, Stress and Coping Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 235-236 ). St. Louis: Mosby. Awarded 4.0 points out of 4.0 possible points. 11.ID: 9476855957 An emergency department nurse is caring for an older client who is a victim of physical abuse. List in order of priority the following nursing actions, with number 1 representing the first action and number 4 the last. Correct A. Checking the client for physical injuries B. Contacting the appropriate state officials to report the abuse C. Contacting a social worker to assist in planning care for the client D. Calling a member of the clergy to address the client’s spiritual needs Rationale: The priority intervention in the event of physical abuse is to check the client for physical injuries. The nurse should then fulfill the legal obligation of reporting suspected elder abuse. The next action is to contact the social worker to obtain assistance in planning care for the client. The client may need the social worker’s help with housing as well. Last, a referral to a member of the clergy is an appropriate intervention if the client desires it. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Remember, physiological needs are the priority. Recall that legal reporting is necessary and should be performed next. To prioritize the remaining options, select the one that involves safety and security as the third action. Review care of the abused elderly client if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Cargiving, Interpersonal Violence HESI Concepts: Stress and Coping – Caregiving, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 427-428). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 12.ID: 9476855949 The parents of an 18-month-old arrive at the emergency department with their unconscious child. Physical examination reveals bruises on the child’s upper arms that resemble grip marks. Which nursing intervention is the priority? A. Stabilizing the child’s physical condition Correct B. Securing a safe environment for the child C. Confronting the parents with regard to suspected abuse D. Contacting the appropriate state officials to report the suspected abuse Rationale: In all child abuse cases, the primary concern is the physical condition of the child. Although contacting appropriate state officials to report suspected abuse and securing a safe environment for the child are both interventions that need to be performed, this child is unconscious, so the priority is to stabilize the child’s physical condition. Confronting the parents about the abuse at this time may cause resentment and conflict in the parents, and the parents might attempt to leave the emergency department with their child. Test-Taking Strategy: Note the strategic word “priority.” Use Maslow’s Hierarchy of Needs theory to answer this question. Recalling that physiological needs are the priority will direct you to the correct option. Review care of the child who has been physically abused if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Dolan, B. & Holt, L. (2013). Accident & Emergency Theory into Practice (3rd ed., pp. 262-263). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points. 13.ID: 9476844034 A nurse in a women’s clinic develops a plan of care for abused women. Which tertiary prevention intervention should be included in the plan of care? A. Identifying families at risk for abuse B. Early case-finding and decisive intervention C. Changing societal views toward domestic abuse D. Assisting abused women in overcoming the physical and psychological effects of abuse Correct Rationale: Primary prevention intervention (here, identifying families at risk for abuse and changing societal views toward domestic abuse) is focused on risk identification and health promotion and prevention of disorders. Secondary prevention interventions (early case-finding and decisive intervention) are focused on early identification and treatment of a problem. Tertiary prevention intervention (helping abused women overcome the physical and psychological effects of abuse) is focused on reducing the residual effects of a disorder and rehabilitation. Test-Taking Strategy: Uses the process of elimination, focusing on the subject, a tertiary prevention intervention. Recalling the definitions of each prevention level will direct you to the correct option. Review these definitions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Cargiving, Interpersonal Violence HESI Concepts: Stress and Coping – Caregiving, Violence Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 739-740). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 14.ID: 9476847258 A nurse assists in caring for victims of an explosion at a local industrial plant. The nurse plans to implement crisis interventions, knowing that this incident is characteristic of: A. A situational crisis B. An individual crisis C. A maturational crisis D. An adventitious crisis Correct Rationale: Adventitious crises are unpredictable tragedies that occur without warning. An individual may experience crisis, but there is no formal type of crisis known as "individual crisis." A situational crisis occurs when a specific external event disturbs an individual’s psychological equilibrium. A maturational crisis involves the normal life transitions that produce changes in individuals and how they perceive themselves, their roles, and their status. Test-Taking Strategy: Use the process of elimination and knowledge of the definition of each type of crisis identified in the options. Focus on the data in the question to identify the correct option. Review the different types of crises if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Caregiving, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 400-401). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 15.ID: 9476858605 A nurse prepares equipment in the electroconvulsive therapy (ECT) suite for a client who will be arriving shortly for therapy. Which items are essential? Select all that apply. A. Thermometer B. Bath blankets C. Pulse oximeter Correct D. Suction device Correct E. Ventilation equipment Correct Rationale: In the ECT suite, blood pressure, cardiac, and electroencephalographic monitors are placed on the client to assess vital functions. Whenever ECT is administered, emergency equipment, including oxygen, suction, and ventilation equipment, must also be available. Bath blankets and a thermometer are not essential equipment. Test-Taking Strategy: Use your knowledge of the ABCs (airway, breathing, and circulation) to identify the correct options. Also note that the correct options are comparable or alike in that they all involve the airway. Review this type of therapy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 598). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 16.ID: 9476858688 A client with depression says, “I always make mistakes. I never do anything right.” Which response by the nurse is therapeutic? A. Saying, “Everyone makes mistakes.” B. Saying, “I know how you are feeling.” C. Saying, “That’s not true. Things will get better.” D. Identifying recent accomplishments that demonstrate the client’s abilities. Correct Rationale: Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. Reminders of the client’s recent accomplishments or personal successes are ways to interrupt the client’s negative self-talk and distorted cognitive view of self. The incorrect options give advice and devalue the client’s feelings. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the incorrect options because they are comparable or alike in that they give advice and devalue the client’s feelings. Focusing on the client’s diagnosis will direct you to the correct option. Review care of the client with depression if you had difficulty with this question. Level of Cognitive Level: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Mood and Affect HESI Concepts: Communication, Mood and Affect Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 267, 273). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 17.ID: 9476841840 A hospitalized client with a diagnosis of delirium often becomes disoriented and confused during the night. Which intervention does the nurse implement? A. Shutting all lights off at night B. Keeping the radio on during the night C. Keeping the television on during the night D. Ensuring a low-stimulation environment at night Correct Rationale: It is important to provide a consistent daily routine and a low- stimulation environment when a client is confused. Noise, including that from radios and televisions, may add to the client’s confusion and disorientation. Lighting is an environmental stimulus that helps maintain and improve orientation. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike (i.e., leaving the radio and television on) first. To select from the remaining options, note that the correct one is the umbrella option. Also note the closed-ended word “all” in the other option. Review measures to be taken for the client who is disoriented and confused if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Cognition, Psychosis HESI Concepts: Cognition – Psychosis, Stress and Coping Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 344). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 18.ID: 9476841874 A psychiatric nurse assists victims of a nightclub fire and their families. Which actions on the part of the nurse is the most importantintervention in the immediate post disaster period? A. Making a list of people who may require mental health services B. Contacting sources of support that may be available for the victims C. Talking to people seeking assistance from the American Red Cross Correct D. Waiting for individuals to identify themselves publicly as being unable to cope Rationale: In the immediate post disaster period, it is important that the nurse is present in places, such as morgues, hospitals, and shelters, where victims are likely to gather. Rather than wait for people to identify themselves publicly as being unable to cope with stress, it is suggested that nurses work with the American Red Cross, talk to people waiting in line to apply for assistance, go door to door, or visit a relocation site. The nurse should ask individuals how they are managing their affairs and explore their reactions to the stress. Test-Taking Strategy: Use the process of elimination. Note that the correct option is the only option that involves dealing directly with people. If you had difficulty with this question, review the psychiatric nurse’s role in responding to a disaster. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Caregiving, Coping HESI Concepts: Grief and Loss, Stress and Coping – Caregiving Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 190-191). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 19.ID: 9476852070 A psychiatric nurse who is a member of a mobile crisis team is called to deal with a person who is threatening to jump off a bridge in a suicide attempt. On arrival at the site, the nurse immediately: A. Tries to grab the client to prevent the jump Incorrect B. Directs law enforcement to prevent the jump C. Tells the client, “You’re making a mistake. I’ll help you.” D. Tries to communicate with the client and develop a therapeutic relationship Correct Rationale: When someone is in the act of preparing to commit suicide, the most appropriate action on the part of the nurse is to communicate with the client in an attempt to develop a therapeutic relationship. The nurse should communicate hope, and hope is often the most therapeutic element in any nursing intervention with a suicidal client. Telling the client he is making a mistake is inappropriate. The other incorrect options are also inappropriate and could prompt the client to follow through with the suicide attempt. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Eliminate the options that are comparable or alike options first in that they involve physically preventing the client from making the jump. To select from the remaining options, use your knowledge of therapeutic communication techniques to identify the correct option. Review the nurse’s role in preventing a suicide attempt if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 194 ). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 20.ID: 9476858646 A client tells the nurse, “I did my hair just like my favorite math teacher wears hers. I hope I can be a good teacher, too.” Which defense mechanism is the client using? A. Projection B. Regression C. Identification Correct D. Intellectualization Rationale: Identification is the process in which a person tries to become like someone he or she admires by taking on the thoughts, mannerisms, or tastes of that person. Projection is attributing one's thoughts or impulses to another person. Regression is retreating to behavior characteristic of an earlier level of development. Intellectualization is the use of excessive reasoning or logic in an attempt to avoid disturbed feelings. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Noting that the client is mimicking another person will direct you to the correct option. Review defense mechanisms if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Mood and Affect, Psychosis HESI Concepts: Cognition – Psychosis, Mood and Affect Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 173). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 21.ID: 9476849450 A nurse assesses a new client hospitalized on the mental health unit. The client is experiencing negative thinking and says, “I’m doomed to failure.” The nurse recognizes that the client’s announcement indicates problems with: A. Self-esteem Correct B. Body image C. Personal identity D. Role performance Rationale: Direct expressions of low self-esteem may include self-criticism. The client exhibits negative thinking and believes that he or she is doomed to failure. The underlying goal of the client is to demoralize himself. The client may describe himself as “stupid,” “no good,” or a “born loser.” The client will view the normal stressors of life as impossible barriers and become preoccupied with self-pity. A body image problem involves the expression of dislike of one’s physical appearance. A problem with personal identity involves the expression of dislike of one’s characteristics. A problem with role performance involves one’s inability to fulfill expected responsibilities. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and the client’s comments about self will direct you to the correct option. Review the characteristics of low self-esteem if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 267). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 22.ID: 9476855940 A psychiatric nurse is sitting with several clients in the day room. A client who has been experiencing delusions and hallucinations says to the nurse, “That television is sending special messages to me.” Which of the following responses by the nurse is therapeutic? A. “The television is on for everyone.” Correct B. “What is the television telling you to do?” C. “The television is not sending messages to you.” D. “What message is the television sending to you?” Rationale: The therapeutic response is the one that provides reality for the client. In the incorrect options, the nurse feeds into the client’s delusions or hallucinations and denies the client the opportunity to see reality. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. Eliminate the options that are comparable or alike and relate to the television sending messages or telling the client what to do. From the remaining options the one that provides a sense of reality to the client is “The television is on for everyone.” Review therapeutic communication techniques for the client experiencing delusions or hallucinations if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition – Psychosis, Communication References: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 366-367, 423). St. Louis: Mosby. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 23.ID: 9476835356 A client with depression says, “My children hate me.” Which response by the nurse is therapeutic? A. “Your children don’t hate you.” B. “Most children go through stages of hating their parents.” C. “Your children should be punished for being disrespectful.” D. “It sounds like you’re having a difficult time with your children.” Correct Rationale: The nurse should use therapeutic communication techniques when responding to a client’s comment. In saying, “Your children don’t hate you,” the nurse is disagreeing with the client’s comment. In the other incorrect options, the nurse criticizes the client’s children. The correct option is an example of the therapeutic response of reflection. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. Eliminate the options that are comparable or alike in that the nurse criticizes others. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental – Family Dynamics Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 27, 306-307). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 24.ID: 9476855982 A client with depression says to the nurse, “My child is dead, and I don’t want to live anymore.” Which comment by the nurse is therapeutic? A. “I understand what you mean.” B. “Tell me more about how you’re feeling.” Correct C. “Every parent struggles with the death of a child.” D. “Your child’s death is not a reason to want to die.” Rationale: In the correct option, the nurse encourages the client to continue expressing her feelings. The incorrect options are nontherapeutic responses in which the nurse does not encourage the client’s self-expression. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only one that encourages the client to express her feelings. If you had difficulty with this question, review these techniques. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Interpersonal Violence HESI Concepts: Communication, Violence References: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 293-294 ). St. Louis: Mosby. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 25.ID: 9476853928 A client on the mental health unit says to the evening nurse, “The staff on the day shift let me smoke two cigarettes. You only let me smoke one.” Which response by the nurse is therapeutic? A. “The day shift staff often breaks the rules.” B. “I’ll speak to the day shift about the smoking rules.” C. “The policy is one cigarette. We’ll follow the policy.” Correct D. “The day shift should not allow you to smoke two cigarettes.” Rationale: The correct option is therapeutic because it provides the client with a clear and direct response regarding the policy on the unit. In the incorrect options, the nurse criticizes the day shift staff. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. Eliminate the options that are comparable or alike in that the nurse is criticizing the day shift staff. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Communication HESI Concepts: Clinical Decision-Making/Clinical Judgment, Communication Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 26.ID: 9476844077 A nurse seeks to deescalate aggressive behavior by a client with schizophrenia. Which actions by the nurse are appropriate in this situation? Select all that apply. A. Standing close to the client B. Being assertive with the client Correct C. Maintaining a nonaggressive posture Correct D. Notifying other staff of the client’s behavior Correct E. Telling the client, “We may need to restrain you.” Rationale: To deescalate aggressive behavior, the nurse should maintain a calm demeanor and nonaggressive posture. The nurse should give the client clear instructions that are brief and assertive, but threatening the client with restraint is inappropriate. The nurse should maintain personal space and not stand closer than about 8 feet (2.4 meters) from the client. Standing close to the client will convey a threatening message. For the sake of safety, it is important to notify other staff members of the client’s behavior. Test-Taking Strategy: Focus on the subject, deescalating aggressive behavior and maintaining a safe environment. Visualize each of the options in terms of how it might protect or seem threatening to the client. This will direct you to the correct options. If you had difficulty with this question, review measures to deescalate aggressive behavior. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 580-582). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 27.ID: 9476847284 A nurse prepares a client for electroconvulsive therapy (ECT). Which concern is of the highest priority? A. Fear B. Anxiety C. Risk for aspiration Correct D. Risk for confusion Rationale: The risk for aspiration is reduced by keeping the client on nothing-by- mouth status for 6 to 8 hours before the procedure, removing dentures, and administering medications as prescribed to diminish oral secretions. Although fear and anxiety may also be concerns, they are of lower priority. Confusion is likely to be a concern after the treatment. Test-Taking Strategy: Use Maslow's Hierarchy of Needs theory to answer the question. Physiological needs are the priority, so select the option that addresses these needs. Additionally, use your knowledge of the ABCs (airway, breathing, and circulation). Airway is the concern with the risk of aspiration. If you had difficulty with this question, review procedures involved in ECT. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 597). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 28.ID: 9476844011 A nurse discovers a hospitalized client with depression wrapping long shreds of torn sheets around his neck. What is the priority nursing concern for this client? A. Self-esteem Incorrect B. Loss of hope C. Coping abilities D. Self-inflicted injury E. Correct Rationale: Because the client is depressed and has been found with long shreds of torn sheets hanging around his neck, the nurse must conclude that a risk for self-inflicted injury exists. Safety is always a priority concern. Self- esteem, loss of hope, and coping abilities may also be concerns in this case but are not the priority. Test-Taking Strategy: Note the strategic word "priority." Focus on the data in the question and use Maslow's Hierarchy of Needs theory. This will direct you to the correct option. Review care of the client with depression if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 258-259, 453). St. Louis: Saunders. Awarded 0.0 points out of 1.0 possible points. 29.ID: 9476850713 A nurse analyzes assessment findings in a client with physical injuries that are suspected by the staff of having been inflicted during family-related violence. Which factor should the nurse first consider? A. The client’s vital signs Correct B. The client’s support system C. Evidence and extent of past injuries D. The client's explanations of how the injuries occurred Rationale: When data obtained from a client who may have been involved in family violence are being analyzed, the physiological well-being of the client is the first concern. The correct option is the only one that directly addresses physiological assessment. Test-Taking Strategy: Note the strategic word “first.” Use your knowledge of the ABCs (airway, breathing, and circulation), and Maslow’s Hierarchy of Needs theory to direct you to the correct option. Review care of the client believed to have been affected by family violence if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 425). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 30.ID: 9476835378 A nurse is caring for a victim of sexual assault. The client's physical assessment is complete. The client's psychological reaction to the assault includes fear, confusion, disorganization, and restlessness. How should the nurse interpret these behaviors? A. Symptoms of impending psychosis B. Normal reactions to a traumatic event Correct C. Evidence that the client is at high risk for suicide D. Indicative of the need for an inpatient psychiatric admission Rationale: During the acute phase following the sexual assault, the client may display any of a wide range of emotional and somatic responses. All of the symptoms noted in the question are part of a normal reaction to an intensely difficult crisis. Although the client's initial reactions may be predictive of later problems, they do not constitute an abnormal initial response. Therefore the remaining options are incorrect. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the initial psychological reaction of a client who has been sexually assaulted. Remember that after a sexual assault the client may display any of a wide range of emotional and somatic responses. Review nursing care for the victim of sexual assault if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 439). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 31.ID: 9476835361 The wife of an alcoholic client began attending Al-Anon groups three weeks ago. The nurse determines that the wife is benefiting from the group when she states: A. "The meetings have helped me see how I caused my husband's violence." B. "Now I realize that I didn’t deserve the beatings my husband inflicted on me." Correct C. "I enjoy attending the meetings because they get me out of the house and away from my husband." D. "I can tolerate my husband's destructive behaviors now that I know that they’re common among alcoholics." Rationale: Al-Anon support groups specifically help families of alcoholics cope with the problems that arise from living with an alcoholic. The wife’s recognition that the beatings were not deserved is the healthiest response, identifying an understanding that the client (husband) is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control. Codependency is not a healthy response. The group is a place to work on issues rather than an escape. Test-Taking Strategy: Use the process of elimination. Recall the client of the question and identify the option that most directly addresses the subject of the question, which is the benefit of attending an Al-Anon group. This will direct you to the correct option. Review the purpose of Al-Anon if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Giddens Concepts: Addiction, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Behaviors- Addiction Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 391). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 32.ID: 9476850740 A client says, “I’ve had so many crying spells over the past several weeks. My doctor says it’s probably depression.” The nurse sees that the client is sitting slumped in the chair and that the client’s clothing is baggy. Further assessment of this client should be focused on: A. Weight loss Correct B. Sleep pattern C. Medication compliance D. Frequency of crying spells Rationale: All of the options are problems that should be addressed; however, the weight loss is the priority, because the obvious ill fit of clothing could signify a substantial problem with nutrition. The client has already told the nurse that the crying spells have been a problem. The need for medication was not addressed in the question. Sleep is affected by depression and should be addressed; however, weight loss is the most important item requiring further assessment. Test-Taking Strategy: Use the process of elimination and Maslow’s Hierarchy of Needs theory to answer the question. Note the relationship between the data in the question and the correct option. In addition, the correct option is related to the physiological need for nutrition. Review the needs of the client with depression if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 262). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 33.ID: 9476853941 A client says, “I spend hours each evening reviewing my day to see whether I behaved appropriately or should have done something differently. I tell myself to snap out of it, but I’m still doing it! It takes me 2 or 3 hours each morning to get dressed, because I want my clothes to be just right.” Which problem is evident in these statements? A. Agoraphobia B. Major depression C. Obsessive-compulsive disorder Correct D. Attention deficit–hyperactivity disorder Rationale: Obsessions are persistent intrusive thoughts that the affected person tries to ignore or suppress. This client wants to “snap out of” this daily review, but the thoughts continue for hours. Compulsions are repetitive behaviors that the client feels driven to perform, such as changing clothes frequently until they are “just right.” Agoraphobia, major depression, and attention deficit– hyperactivity disorder are not associated with the characteristics described in the question. Test-Taking Strategy: Focus on the data in the question and use the process of elimination. Noting the repetitiveness of behaviors that the client describes should provide you with the clue that will direct you to the correct option. If you had difficulty answering this question, review the characteristics of obsessive- compulsive disorders. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Mood and Affect, Psychosis HESI Concepts: Cognition – Psychosis, Mood and Affect Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 179). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 34.ID: 9476844001 A phlebotomist prepares to draw blood from a client experiencing delusions. While in the laboratory, the client begins shouting, "You're all bloodsuckers. Get me out of here." Which response by the nurse is therapeutic? A. “Let me help you out of here.” B. "I'm leaving until you calm down." C. "These people are not bloodsuckers." D. "It must be scary to think others want to hurt you." Correct Rationale: The correct option recognizes the client’s feelings and helps the client focus on the emotion underlying the delusion but does not argue with it. One danger in directly attempting to change the client's mind is that the client may cling more strongly to the delusion. The inappropriate responses deny or argue with the client’s beliefs, which may jeopardize the nurse-client relationship. Test-Taking Strategy: Focus on the client’s diagnosis and the client’s statement. Use your knowledge of therapeutic communication techniques and address the client’s feelings. The correct option is focused on the client’s feelings. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition – Psychosis, Communication Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 321). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 35.ID: 9476847274 A drunken client is awaiting treatment in the emergency department. The client becomes loud and aggressive when told that there will be a short delay before treatment. Which response by the nurse is therapeutic? A. Waiting until the behavior escalates before intervening B. Attempting to talk with the client to deescalate the behavior C. Informing the client, “You will be asked to leave if this behavior continues.” D. Offering to take the client to an examination room until treatment can be started Correct Rationale: Safety of the client, other clients, and staff is of priority concern. Offering to take the client to an examination room until she is treated separates the client from others and provides a less stimulating environment where the client can maintain her dignity. Waiting until the behavior escalates before intervening is incorrect because it allows the client to become even more agitated and a threat to others. Attempting to talk with the client to deescalate behavior is not likely to be productive, because the client is intoxicated and her reasoning impaired. Informing the client that she will be asked to leave if the behavior continues would only further aggravate an already agitated individual. Test-Taking Strategy: Use the process of elimination, specifically noting that the client is intoxicated. The correct option most directly addresses the situation and the behavior and feelings of the client. Review appropriate interventions for dealing with an intoxicated client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence References: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th ed., p. 514). St. Louis: Elsevier. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 170). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 36.ID: 9476848509 As the nurse prepares a client for a coronary artery bypass graft, the client asks, “Will I be OK?” Which response by the nurse is therapeutic? A. “I hope you’ll be fine.” B. “Let’s talk about how you’re feeling.” Correct C. “Don’t worry. You have an excellent surgeon.” D. “You need this surgery to avoid serious problems.” Rationale: The correct response offers self and encourages the client to share feelings and fears. The incorrect options block communication and may increase the client’s anxiety. False reassurance is nontherapeutic. The client needs an opportunity to talk about the impending surgery. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Note that the client is expressing a desire to discuss the surgery and its possible outcomes. The correct option addresses the client’s feelings and is an example of open-ended communication. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Anxiety, Communication HESI Concepts: Communication, Mood and Affect – Anxiety Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123, 177). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 37.ID: 9476848588 A nurse prepares to care for a client with a diagnosis of Tourette syndrome. The medical record indicates that the client experiences motor tics. Which finding would the nurse expect to note during assessment of this client? A. Grunting sounds B. Tongue protrusion Correct C. Uttering of obscenities D. Consistent yelping sounds Rationale: Tourette syndrome involves motor and verbal tics that cause marked distress and significant impairment of social and occupational function. Motor tics usually involve the head but may also involve the torso and limbs. The most common first symptom is a single tic, such as eye-blinking. Other motor tics include tongue protrusion, touching, squatting, hopping, skipping, retracing of steps, and twirling when walking. Vocal tics include words and sounds such as barks, grunts, yelps, clicks, snorts, sniffs, and coughs. Coprolalia, the uttering of obscenities, is present in some individuals with this disorder. Test-Taking Strategy: Note the strategic phrase “motor tics” in the question. Using the process of elimination and eliminate the options that are comparable or alike — here, all of the incorrect options involve verbal behaviors. Review manifestations of this disorder if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect Content Area: Mental Health Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 507-508). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 38.ID: 9476844015 A nurse assesses a client with early-onset Alzheimer’s disease. The nurse asks the client, “How was your weekend?” The client responds by saying, “It was great. I discussed war campaigns with the president and had dinner at the White House.” Which defense mechanism is evident? A. Hiding B. Apraxia C. Perseveration D. Confabulation Correct Rationale: Confabulation is a defense mechanism and an unconscious attempt to maintain self-esteem by providing information that is not true about an event or situation. Hiding is a form of denial and an unconscious protective defense against the terrifying possibility of losing one’s place in the world. Apraxia is characterized by the loss of purposeful movement in the absence of motor or sensory impairment. Perseveration is the repetition of phrases or behaviors. Test-Taking Strategy: Focus on the subject, a defense mechanism, and the statement made by the client. Note the option that is not a defense mechanism (apraxia) and eliminate it. To select from the remaining options, focus on the statement of the client; this will direct you to the correct option. If you had difficulty with this question, review defense mechanisms and findings associated with dementia. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Cognition HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cognition Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 346). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 39.ID: 9476841854 A nurse reviews the record of a client and notes that the client experiences flashbacks. Which of the following conditions is most often associated with flashbacks? A. Schizophrenia B. Anxiety disorder C. Hallucinogenic drug use Correct D. Obsessive-compulsive disorder Rationale: Flashbacks, a common effect of hallucinogenic drugs, are transitory recurrences in perceptual disturbance caused by a person’s earlier hallucinogenic drug experiences. They occur when the person is in a drug-free state. Visual distortions, time expansion, loss of ego boundaries, and intense emotions may occur. The experience of flashbacks is also characteristic of posttraumatic stress disorder. They do not occur in schizophrenia or obsessive- compulsive disorder. Anxiety disorder is a term that encompasses posttraumatic stress disorder as one of its components. Test-Taking Strategy: Focus on the subject, flashbacks. Recalling that flashbacks occur with the use of hallucinogenic drugs will direct you to the correct option. Review the characteristics of flashbacks if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Mood and Affect, Psychosis HESI Concepts: Cognition – Psychosis, Mood and Affect Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 449). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 40.ID: 9476853989 After an attack in a park while jogging, a client experiences posttraumatic stress disorder. The client, visibly anxious, tells the nurse that she now avoids all exercise and parks but says, “I don’t want to feel this way.” Which response by the nurse is appropriate? A. “I know it’s difficult now, but try not to worry so much.” B. “Everything will be all right if you just give it more time.” C. “I can see that you’re upset about this. Let’s talk some more about it.” Correct D. “Why don’t you just go jogging in a park and get it out of your system?” Rationale: The therapeutic response encourages the client’s expressions of feelings by indicating that the nurse is aware of the client’s feelings and promoting continued communication. Each of the incorrect options neither acknowledges the client’s concerns nor encourages further communication. Giving advice and false reassurance are not therapeutic techniques. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that addresses the client’s feelings. Review these techniques if you had difficulty with this question Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Interpersonal Violence HESI Concepts: Communication, Violence Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 224). St. Louis: Mosby. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 41.ID: 9476844046 A client hospitalized in a mental health unit is restrained after becoming extremely violent. Which finding indicates to the nurse that the client can be removed from the restraints? A. The client dozes after a sedative is administered B. The client apologizes and says, “It won’t happen again.” C. The client divulges all of the reasons for the violent behavior D. The client initiates no aggressive acts for 30 minutes after the release of two leg restraints Correct Rationale: The best indicator that the client’s behavior is under control is when the client refrains from aggression after partial release from the restraints. Generally a structured reintegration, begun by reducing a client's four-point restraints to two-point restraints, is initiated. If the client continues to exhibit nonaggressive behavior, the remaining restraints are removed. The incorrect options are not indicators that the client’s behavior is under control. Test-Taking Strategy: Use the process of elimination noting the subject, removal of restraints. Noting the words “no aggressive acts” will direct you to the correct option. Review the procedure for the use of restraints if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Giddens Concepts: Interpersonal Violence, Safety HESI Concepts: Safety, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 468-469, 472). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 42.ID: 9476841800 A client with bipolar disorder has been hospitalized for 4 days. Today in group therapy the client offered helpful suggestions in regard to another client’s problem. The nurse concludes that the client’s behavior is representative of: A. Acting out B. Manipulation C. Improvement Correct D. Attention-seeking Rationale: The behavior demonstrated by the client is appropriate during hospitalization. There is no evidence in the question that the client is acting out (which is an attention-seeking behavior), being manipulative, or seeking attention. Test-Taking Strategy: Focus on the data presented in the question. Eliminate the options that are comparable or alike (acting out and attention-seeking). To select from the remaining options, focus on the data in the question, which will direct you to the correct option. Review the signs of improvement in a hospitalized client if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analyzing Content Area: Mental Health Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 316). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 43.ID: 9476835390 A client says to the nurse, “My cancer is going to shorten my life, so I’m making a will that leaves my money to charity. Do you think I can get into heaven that way?” Which response by the nurse is therapeutic? A. “I don’t believe that giving away money will help a person get into heaven.” B. “I don’t believe in heaven, but it certainly seems like a good plan if it exists.” C. “You feel that a charitable contribution will get you into heaven if your cancer ends your life?” Correct D. “You’re going to live a long healthy life because your cancer was caught early and the cure rate is high.” Rationale: The correct option involves the therapeutic communication technique of reflection, in which the ideas of the client are presented back to the client for the client to consider. It is employed when a client asks the nurse for approval or judgment because it helps the nurse intervene with a nonjudgmental response. The client is expressing concern, and, although the illness may be cured, it is vital to actively listen and to be sensitive to expression of concerns and fear. The incorrect options give an opinion, express approval, use false reassurance, or offer advice and lectures to the client, all of which are closed- ended techniques that do not facilitate expressions of feelings. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Coping HESI Concepts: Communication, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 44.ID: 9476835346 A nurse is providing medication instructions to a client who is starting disulfiram. Which statements by the client indicate that the client understands the information? Select all that apply. A. “It’s important to take this medication every day.” Correct B. “Painting my living room will be a good distraction.” C. “I need to check the labels on over-the-counter medications carefully.” Correct D. “If I take this medication and drink alcohol, I’ll feel sick within 8 hours.” E. “It’s important to take this medication when I have the urge to start drinking.” Rationale: Disulfiram can help motivated clients avoid impulsive drinking of alcohol because it interacts with alcohol, resulting in unpleasant physical effects. The medication must be taken daily and is often administered under supervision. The medication reaction begins minutes to a half-hour after alcohol use, and the effects — facial flushing, headache, neck pain, tachycardia, decreased blood pressure, sweating, nausea and vomiting, and respiratory distress — may last for as long as 2 hours. The client should avoid “hidden” sources of alcohol in foods and other medications. The client should also avoid inhaling fumes from alcohol-containing substances such as wood stain, paint, and furniture-stripping products. Test-Taking Strategy: Specific knowledge regarding disulfiram (Antabuse) therapy is needed to answer this question. Also use general medication guidelines to answer correctly. Remember that this medication interacts with alcohol. Review information on disulfiram if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 462). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 45.ID: 9476835374 A nurse counsels a client with an alcohol disorder and the client’s spouse. The spouse says, “I’ve covered up the drinking because I made a commitment to our marriage, but now our children won’t come to visit.” The nurse should refer the spouse to a support group for: A. Alcoholics B. Caregivers C. Codependents Correct D. Substance abusers Rationale: The description of the spouse’s behavior indicates that the spouse is codependent. Codependence involves overly responsible behavior; that is, doing for another person what that person could be doing for himself or herself. The incorrect options identify addicted people, not people connected to the addict, and a person who is involved with caring for an addicted significant other on a daily basis. Test-Taking Strategy: Focus on the data in the question and note that the spouse exhibits a pattern of overly responsible (codependent) behavior. This will direct you to the correct option. Review support groups if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Addiction, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Behaviors- Addiction Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 450-451, 465). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 46.ID: 9476844042 A client hospitalized with severe depression is withdrawn and exhibits poor motivation and concentration. Which activity should the nurse plan for this client? A. Drawing Correct B. Cooking class C. Dance therapy D. Small-group discussions Rationale: When a client is severely depressed, the client should be involved in activities that require little concentration and have no elements of being “right” or “wrong.” As the client’s condition improves, the client may become involved in activities with small groups, such as cooking class, dance therapy, and small group discussions. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve activities with small groups. Review care of the client with severe depression if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Caregiving, Mood and Affect HESI Concepts: Mood and Affect, Stress and Coping – Caregiving Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 315, 373). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 47.ID: 9476840132 A nurse cares for a severely depressed client who is mute. Which comment by the nurse to the client is appropriate? A. “Are you having trouble talking?” B. “Everyone feels sad once in a while.” C. “There are many new pictures on the wall.” Correct D. “Things will look up for you, just wait and see.” Rationale: When a client is not ready to talk, direct questions may raise the client’s anxiety level. Pointing to commonalities in the environment draws the client into, and reinforces, reality. The nurse should avoid platitudes, which tend to minimize the client’s feelings and can increase feelings of guilt and worthlessness. The nurse also should avoid statements that provide false reassurance. Test-Taking Strategy: Use the process of elimination and note that the client is mute. Eliminate the option in which the nurse asks the client a question, because this may increase the client’s anxiety level. Next eliminate the nontherapeutic responses. Review care of the client who is mute if you have difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Caregiving, Mood and Affect HESI Concepts: Mood and Affect, Stress and Coping – Caregiving Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., pp. 324-325). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 48.ID: 9476841810 A nurse provides dietary instructions to a client who will be taking tranylcypromine. Which foods should the nurse tell the client to avoid? Select all that apply. A. Broccoli B. Avocado Correct C. Red meat D. Cream cheese E. Pickled herring Correct Rationale: Tranylcypromine is a monoamine oxidase inhibitor (MAOI). The client taking an MAOI needs to avoid consuming tyramine-containing foods. This includes all cheeses except cottage and cream cheese and Danish Brie and Danish Camembert. Other foods containing tyramine include avocado, bananas, caviar, canned figs, pickled herring, liver, smoked foods, yeast extracts, and broadbean pods. Test-Taking Strategy: Focus on the subject, foods that the client needs to avoid. Recalling that tranylcypromine is an MAOI and remembering foods containing tyramine that need to be avoided will assist in answering the question. Review this medication and the foods that contain tyramine if you have difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 272). St. Louis: Saunders. Awarded 2.0 points out of 2.0 possible points. 49.ID: 9476855971 A client, upset, says, “My ex-wife’s new husband is being relocated to a job across the country, so now I’ll only see my child on holidays and school vacations.” Which response by the nurse is therapeutic? A. “Can you relocate to be closer to your child?” B. “That’s too bad. Maybe the court can stop your ex-wife from moving away.” C. “Have you talked to your ex-wife about giving custody to you and your new wife?” D. “This must be very difficult for your child to move away from you, school, and friends.” Correct Rationale: The therapeutic nursing response is the one that supports the client in seeing events from his child’s viewpoint. Adults are better able to adjust to life changes than are younger people. It is important that both parents focus on the disruption that a move causes for children, not just themselves. Asking, “Can you relocate to be closer to your child?” is advice, which is nontherapeutic. Saying, “That’s too bad. Maybe the court can stop your ex-wife from moving away” is a social response that offers a conflict-oriented suggestion. Asking, “Have you talked to your ex-wife about giving custody to you and your new wife?” offers a suggestion that is not supportive and is conflict-oriented. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental – Family Dynamics Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 50.ID: 9476858698 A nurse provides medication instructions to a client who is taking lithium carbonate . Which statements by the client indicate an understanding of the instructions? Select all that apply. A. “I should weigh myself several times a day.” B. “I should take this medication with my meals.” Correct C. “I need to cut down on my fluid intake while I’m taking the medication.” D. “I need to call my doctor if I get diarrhea or vomiting or start to sweat a lot.” Correct E. “My blood level of medication needs to be monitored closely while I take this medication.” Correct Rationale: Lithium carbonate is used to treat bipolar disorder. Lithium is irritating to the gastric mucosa and therefore should be taken with meals. Because the therapeutic and toxic dosage ranges are so close, the lithium blood level must be monitored very closely, with more frequent checks at first and a check every several months thereafter. The client should be instructed to stop taking the medication if excessive diarrhea, vomiting, or diaphoresis occurs and to inform the health care provider if any of these problems develops, because it could be an indication of toxicity. The client should weigh him- or herself several times a week (not several times a day). A normal diet and normal salt and fluid intake (1500 to 3000 mL/day of fluid, or six 12-oz [180 ml] glasses) should be maintained, because lithium decreases sodium reabsorption in the renal tubules, which could result in sodium depletion. A low sodium intake causes an increase in lithium retention and could lead to toxicity. Test-Taking Strategy: Recall that lithium carbonate can cause toxicity. Eliminate the option that includes the words “several times a day.” Next remember that generally it is important to teach clients to maintain adequate fluid intake. This principle will direct you to the correct options. Review the client teaching points for his medication if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 296). St. Louis: Saunders. Awarded 3.0 points out of 3.0 possible points. 51.ID: 9476849489 Buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse, providing information to the client about the medication, should tell the client that: A. The medication often causes dependency B. Mild dizziness and nervousness may occur Correct C. The medication produces profound sedation D. The medication begins to work immediately E. Rationale: Buspirone hydrochloride is used in the management of anxiety disorders. Dizziness, nausea, headaches, nervousness, lightheadedness, and excitement, which generally are not major problems, are side effects of the medication. The advantage of this medication is that it is not sedating or addicting. The medication takes 2 to 4 weeks for therapeutic effects to appear. Test-Taking Strategy: Specific knowledge regarding the side effects and toxic effects of buspirone hydrochloride is required to answer this question. Recalling that this medication is an antianxiety agent will assist in directing you to the correct option. If you are unfamiliar with this medication, review this content. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 535). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 52.ID: 9476847227 A nurse cares for a hospitalized client who has been taking clozapine for the treatment of schizophrenia. Which laboratory result will the nurse specifically check to assess the client for an adverse reaction associated with the use of this medication? A. Platelet count B. Cholesterol level C. Blood urea nitrogen D. White blood cell count Correct Rationale: Clozapine is often reserved for clients with treatment resistant illness because of its side effects of agranulocytosis, seizures, and myocarditis. Prescribers must follow a treatment protocol that incude entering clients in a national registry, monitoring white blood cell count weekely for 6 months and then biweekly for as long as clients are taking the medication, and writing prescriptions for only 1 to 2 weeks at a time. For the refractory client, however, clozapine may make a significant difference in treatment outcome. The remaining laboratory tests are not associated with the use of this medication. Test-Taking Strategy: Specific knowledge regarding clozapine is needed to answer correctly. Recalling that hematological reactions may occur in the client taking clozapine will direct you to the correct option. If you are unfamiliar with these adverse reactions and the laboratory results that need to be closely monitored, review this medication. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Assessment, Safety Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 551). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 53.ID: 9476850770 A nurse employed in a prison infirmary cares for a client recuperating from a stab wound. The client says, "You have beautiful eyes, and you smell nice." Which response or action on the part of the nurse would be therapeutic? A. "Thank you for noticing." B. "Do you think you’re being appropriate?" C. "I'm here to change your dressing, not discuss my eyes or how I smell." Correct D. Saying nothing in an attempt to discourage client's inappropriate behavior Rationale: A client in prison is knowledgeable about the rules for behavior in the correctional setting. Many clients will test the nurse's capacity to be manipulated and will make inappropriate statements. These behaviors should be addressed directly. The nurse should define his or her role without being judgmental or providing an opening for a regressive struggle. Social responses or saying nothing may be misinterpreted by the client as an indication that the nurse welcomes the compliments. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and knowledge regarding care of the client in prison. The correct option is the only one in which the client’s behavior is directly addressed. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Professional Identity HESI Concepts: Communication, Professional Behaviors/Professionalism Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123, 149). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 54.ID: 9476840102 A nurse is caring for a client hospitalized with depression. Which comment by the nurse upon entering the client’s room is appropriate? A. “You look nice this morning.” B. “I like the way you did your hair.” C. “Don’t worry. Things will look up for you.” D. “You’re wearing a new dress this morning.” Correct Rationale: The depressed client sees the negative side of everything. Giving recognition without giving approval is therapeutic. The incorrect options give approval or false reassurance, both nontherapeutic communication strategies. Saying, “You look nice this morning” or “I like the way you did your hair” might be interpreted as “I did not look nice yesterday” or “The nurse didn’t like the way I did my hair yesterday.” Test-Taking Strategy: Note the diagnosis of the client and read each option carefully. Select the option that will not be subject to negative interpretation, the neutral comment. Review techniques for therapeutic communication with the depressed client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Professional Identity HESI Concepts: Communication, Professional Behaviors/Professionalism Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 254-255). St. Louis: Saunders. Awarded 0.0 points out of 1.0 possible points. 55.ID: 9476841880 A nurse plans care for a client experiencing psychomotor agitation. Which activities would be appropriate for the client? Select all that apply. A. Playing chess B. Reading magazines C. Playing table tennis D. Playing simple card E. Filling cups with ice for afternoon snacks Correct Rationale: It is best to provide the client with psychomotor agitation activities that involve the use of the hands and gross motor movement such as table tennis, volleyball, finger painting, drawing, working with clay, and exercising. Filling cups with ice also achieves this intent. These activities provide the client a more appropriate way of discharging motor tension than pacing or wringing the hands. Playing simple card games and reading magazines are sedentary activities. Playing chess requires concentration and intensive use of thought processes. Test-Taking Strategy: Note the client’s diagnosis and recall that activities that involve the use of hands and gross motor movements are best for such a client. Eliminate the option of an activity that will require concentration, which this client may not be able to manage. Note the options that will not provide a method of discharging motor tension; this will assist you in eliminating these options. Review care of the client with psychomotor agitation if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Mobility, Mood and Affect HESI Concepts: Mobility, Mood and Affect – Anxiety References: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 315). St. Louis: Mosby. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 257). St. Louis: Saunders. Awarded 0.0 points out of 2.0 possible points. 56.ID: 9476855931 A nurse develops a plan of care for a client with depression who has experienced a 24-lb (11 kg) weight loss in the past 2 months. Which intervention should the nurse include in the plan of care? A. Offering high-calorie foods and fluids B. Offering three well-balanced meals during the day C. Sitting with the client to make food and fluid choices from the menu Correct D. Providing a private place where the client may eat alone if she wants Rationale: The client should be asked which foods or drinks he or she likes and offered choices. Sitting with the client during the activity is therapeutic use of self by the nurse. This strategy, reinforcing the idea that someone cares, may raise the client’s self-esteem and serve as an incentive for the client to eat. Simply offering high-calorie meals and snacks does not ensure that the client will eat. The client is more likely to eat the foods provided if he or she has selected the foods. Someone should remain with the client during meals. Test-Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike in that food is being offered to the client. To select from the remaining options, focus on interventions that promote nutrition and demonstrate that the nurse has therapeutically engaged in the relationship. If you had difficulty with this question, review measures to improve food intake in the depressed client. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Mood and Affect, Nutrition HESI Concepts: Mood and Affect, Nutrition Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 262). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 57.ID: 9476861066 A client with delirium suddenly picks up a can of soda from the meal tray and threatens to throw it at the nurse. How should the nurse respond? A. “Hitting me or anyone else is not allowed.” Correct B. “If you hit me, I will put you into restraints.” C. “You will get an injection if you keep threatening to hit me or anyone else.” D. “The seclusion room is empty. That’s where you will go if you threaten to hit me.” Rationale: When a client’s behavior becomes physically abusive, the nurse must set limits on the behavior. Communication with a client experiencing delirium should be simple and clear. The incorrect options threaten the client and jeopardize the client’s rights. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they threaten the client’s rights. If you had difficulty with this question, review appropriate care of the client with delirium who is physically abusive. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Communication, Interpersonal Violence HESI Concepts: Communication, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 340-341). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 58.ID: 9476861077 A client with obsessive-compulsive disorder, upset and agitated, walks repeatedly around the nursing unit, following the same route each time. The client says to the nurse, “Walk with me.” Which response by the nurse is appropriate? A. “I’m sorry I can’t, but I will find someone else to walk with you.” B. “You should rest for a while. I’ll walk with you back to your room.” C. “I’m busy now, but we can talk tomorrow afternoon when I come back.” D. “I can see that you’re upset. I can walk and talk with you for 15 minutes.” Correct Rationale: The correct response acknowledges the client’s feelings and provides an avenue for release of the client’s anxieties. Each of the incorrect options is a block to communication. The wording of the incorrect options does not acknowledge the client’s feelings. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the options that do not deal with the client’s concerns or promote further communication. Remember that the client’s feelings need to be addressed first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Coping HESI Concepts: Communication, Stress and Coping Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123, 182). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 59.ID: 9476835386 A client hospitalized with schizophrenia says to the nurse, "Get your goat. Go out and vote. Don’t be a cut throat. Row your boat.” How should the nurse document the client’s behavior? A. Echolalia B. Word salad C. Clang associations Correct D. Thought broadcasting Rationale: Repetition of words or phrases that are similar in sound but in no other way, known as clang association, is an assessment finding in some clients with schizophrenia. Clang associations often take the form of rhyme. Echolalia, the pathological repeating of another’s word, is often seen in people with catatonia. Word salad is a mixture of phrases that is meaningless to the listener and perhaps to the speaker as well. Thought broadcasting is the belief that others can know one’s thoughts. Test-Taking Strategy: Use the process of elimination. Focus on the client’s statement. Recalling that rhyming is associated with clang associations will direct you to the correct option. Review altered thought and language patterns in schizophrenia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Giddens Concepts: Communication, Psychosis HESI Concepts: Communication, Behaviors Content Area: Mental Health Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 312). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 60.ID: 9476853950 A client is hospitalized after falling asleep at the wheel of the) car, hitting and killing a pedestrian crossing the street. The nurse caring for the client notes that the client is crying and upset. What is the appropriate reaction by the nurse? A. Providing private time for the client to grieve B. Administering a sedative and contacting the healthcare provider C. Saying to the client, “I see that you’re crying. I’m here to talk to you.” Correct D. Telling the client that the pedestrian’s death was a result of his falling asleep at the wheel Rationale: Making a neutral observation and offering self are therapeutic communication techniques. In the interest of safety, the client needs supervision. The nurse should assess the client and provide comfort measures before administering a sedative or contacting the healthcare provider. Additionally, a prescription must be obtained before administering a sedative. Telling the client that the pedestrian’s death was a result of his falling asleep at the wheel is inappropriate and a block to communication. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Select the option that encourages the client to express feelings. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Caregiving, Communication HESI Concepts: Caregiving, Communication Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 61.ID: 9476841823 A nurse is assigned to care for a client with a diagnosis of catatonic stupor. When the nurse enters the client’s room, the client is lying on the bed in a fetal position. What should the nurse do? A. Leave the client alone B. Sit beside the client in silence Correct C. Move the client into the clients’ dayroom D. Ask the client direct questions to encourage talking Rationale: Clients who are withdrawn may be immobile and mute and require consistent, repeated approaches. Interventions include the establishment of interpersonal contact and maintenance of safety. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The client should not be left alone. It is not appropriate to place the client in a public place. Asking direct questions of this client is not therapeutic. Test-Taking Strategy: Use the process of elimination. Eliminate first the option of leaving the client, realizing that you would not leave the client alone. Next eliminate the option that involves moving the client to a public place. Asking direct questions of this client is not therapeutic, so eliminate this option. The correct option is the best action because it provides for client supervision and communication as appropriate. Review care of the client in a catatonic stupor if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Caregiving, Psychoses HESI Concepts: Caregiving, Behaviors Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 353-354). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 62.ID: 9476835382 A client diagnosed with schizophrenia tells the nurse. “There are voices outside the window telling me what to do all the time. Can you hear them? What should I tell them?” How should the nurse respond initially? A. “Yes, I can hear them, too.” B. “What are the voices telling you?” Correct C. “There are no voices. You’re just ill.” D. “They’ll go away if you ignore them.” Rationale: The nurse should first assess the situation. When a client is experiencing an auditory hallucination, it is important initially to determine what the voices are saying or telling the client to do. Suicidal or homicidal messages, if heard by the client, necessitate the implementation of safety measures as a priority. The incorrect options are inappropriate and do not reinforce reality or provide important information to the nurse. Test-Taking Strategy: Note the strategic word “initially” in the query of the question. Use prioritization skills and your knowledge of therapeutic communication techniques to answer the question. The correct answer is the only option that will provide the nurse with important additional assessment data. If you had difficulty with this question, review interventions for the client experiencing auditory hallucinations. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Communication, Cognition-Psychosis Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 351-352). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 63.ID: 9476861016 A client has a diagnosis of dependent personality disorder. Which goal is most appropriate for this client? A. Adherence to a no-self-harm contract B. Avoiding situations that increase anxiety C. Using the problem-solving process effectively Correct D. Refraining from engaging in compulsive behaviors Rationale: The client with dependent personality disorder exhibits an unusually strong need to be cared for and has difficulty making personal choices and every day decisions in fear of making the wrong decision. An appropriate goal would be for the client to use the problem-solving process effectively in everyday situations. The client described in the question does not exhibit any suicidal traits, nor does he suffer from an obsessive-compulsive personality disorder or an anxiety disorder. Test-Taking Strategy: Use the process of elimination. Noting the client’s diagnosis and the strategic word “dependent” will direct you to the correct option. Review the characteristics of dependent personality disorder if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Coping, Development HESI Concepts: Developmental, Stress and Coping Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 220-221). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 64.ID: 9476855908 A nurse completes the initial assessment for a new client in a maximum-security prison who has been sentenced to serve a life sentence without parole. What should the nurse include as a priority in the treatment plan for this client? A. Rehabilitation B. Vocational training C. Assessment for suicide risk Correct D. Assessment for homicide risk Rationale: The nurse preparing a treatment plan for a client in prison must integrate the built-in realities and limitations of the correctional setting and its compulsory regimen into the treatment plan. The incidence of suicide among inmates in correctional settings is higher than that among the general population. Assessment for self-violence and suicidal potential is critical for a client who has been sentenced to serve life without parole. Rehabilitation and vocational training are of limited use for such a client. Assessment for homicide risk may be a part of the plan but is not the priority. Additionally, there is no information in the question to support an assessment for homicide risk. Test-Taking Strategy: Use the process of elimination, focusing on the client data in the question. Although some rehabilitation and vocational training may be part of the care plan, it is not the priority for a client who will be serving a life sentence without parole. Note the options that are part of the lethality assessment, but remember that this assessment must deal first with self- directed violence. Review the importance of a suicidal assessment if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Interpersonal Violence, Safety HESI Concepts: Safety, Violence Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 326-327). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 65.ID: 9476849463 A home health nurse provides instructions to the spouse of a client taking tacrine hydrochloride for the management of moderate dementia associated with Alzheimer’s disease. Which information should the nurse provide to the spouse? A. “Administer the medication with food.” B. “If a dose is missed, double up on the next dose.” C. “If flu-like symptoms occur, notify the healthcare provider immediately.” D. “If you see a change in the color of the skin or stool, notify the healthcare provider.” Correct Rationale: Liver toxicity is an adverse effect of tacrine and may be signaled by changes in the color of the skin or stool. The client or spouse should never be instructed to double the next dose of any medication if the previous dose is missed. Tacrine may be administered between meals on an empty stomach or, if gastrointestinal upset occurs, with meals. Flu-like symptoms (i.e., headache, nausea, vomiting, diarrhea, dizziness) are frequent side effects of the medication. Test-Taking Strategy: Knowledge regarding the teaching points for tacrine is required to answer this question. Use your knowledge of general medication guidelines to answer. Also, recalling that liver toxicity is one adverse reaction associated with the use of the medication will direct you quickly to the correct option. If you are unfamiliar with the use of this medication and its potential adverse reactions, review this content. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Cellular Regulation, Client Education HESI Concepts: Cellular Regulation, Teaching and Learning/Patient Education References: Lehne, R. (2013). Pharmacology for nursing care (8th ed., p. 206). St. Louis: Saunders. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 356). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 66.ID: 9476835338 The lithium level in a client taking lithium carbonate is 2.3 mEq/L. Which assessment finding would the nurse expect to note in the client based on this laboratory value? A. Flaccidity B. Constipation C. Stable mood D. Blurred vision Correct Rationale: This laboratory result indicates lithium toxicity. The maintenance blood level of lithium should range between 0.4 and 1.3 mEq/L. At levels of 1.5 to 2.0 mEq/L, the client will experience vomiting, diarrhea, coarse hand tremors, confusion, lack of coordination, and muscle hyperirritability. At levels of 2.0 to 2.5 mEq/L, the client will experience blurred vision, muscle twitching, hypotension, a large output of dilute urine, stupor, or seizures. At a level of 2.5 mEq/L or higher, urinary and fecal incontinence occurs. Cardiac dysrhythmias, peripheral vascular collapse, and death may also occur. Test-Taking Strategy: Knowledge regarding the clinical manifestations associated with various lithium levels is required to answer this question. Noting the level in the question and recognizing that it reflects toxicity will assist in answering correctly. If you are unfamiliar with the therapeutic lithium level and the signs of toxicity, review this content. Level of Cognitive Ability: Analyzing Client Needs: Physiological integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Cellular Regulation, Clinical Judgment HESI Concepts:Assessment, Cellular Regulation Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 295). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 67.ID: 9476861062 Lorazepam has been prescribed for a client for management of anxiety. Which finding in the client’s history would indicate the nurse the need to confer with the healthcare provider before administering the medication? A. Diabetes B. Hypothyroidism C. Narrow-angle glaucoma Correct D. Coronary artery disease Rationale: Lorazepam is contraindicated in people with hypersensitivity to benzodiazepines, as well as coma, pre-existing central nervous system depression, uncontrolled severe pain, and narrow-angle glaucoma. It is also contraindicated in women who are pregnant or breastfeeding. Lorazepam is safe for clients with diabetes, hypothyroidism, and coronary artery disease. Test-Taking Strategy: Knowledge regarding the contraindications to the use of lorazepam is required to answer this question. Remember that lorazepam is contraindicated in a client with glaucoma. If you are unfamiliar with these contraindications, review this content. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Pharmacology Giddens Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing Care, Safety Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 720) St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 68.ID: 9476835396 A nurse assesses a client hospitalized with schizophrenia for whom risperidone has been prescribed. Which laboratory test result should the nurse check before administering the first dose of this medication? A. Platelet count B. Clotting studies C. Liver function studies Correct D. International normalized ratio (INR) Rationale: Baseline assessment before the initiation of risperidone treatment includes kidney and liver function tests. This medication is used with caution, generally with an initial dosage reduction, in clients with renal or hepatic impairment, clients with underlying cardiovascular disorders, and older or debilitated clients. Risperidone does not alter clotting factors, so the incorrect options do not apply. Test-Taking Strategy: Knowledge regarding the precautions associated with the use of risperidone is required to answer this question. If you knew that the medication was used cautiously in clients with renal or hepatic impairment, you would easily identify the correct option. Also note that the incorrect options are comparable or alike in that they are both related to clotting. If you are unfamiliar with the contraindications to the use of this medication, review this content. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Pharmacology Giddens Concepts: Cellular Regulation, Clinical Judgment HESI Concepts:Assessment, Cellular Regulation Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 327). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 69.ID: 9476844053 A client in the mental health unit points to another client and says to the nurse, “He’s been working with the Taliban, pouring anthrax into our water supply.” How should the nurse respond to the client? A. “That’s why we’ve locked him in this unit with you.” B. “Did you actually see him pour anthrax into the water supply?” C. “Are you saying that you don’t feel safe about drinking our water?” Correct D. “Remember, the treatment team told you to ignore these thoughts because they aren’t true.” Rationale: The nurse appropriately responds by addressing the client’s feelings associated with the delusional thinking. The correct response involves reflection, a therapeutic communication technique. After responding to the client’s feelings, the nurse should address the client in an open, honest, and matter-of-fact way to ease the client’s suspiciousness. The incorrect responses do not deal directly with the client’s concerns, which may result in a regressive struggle with the client. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques noting that the client is delusional. Remember that it is most important to maintain reality with the client. This will direct you to the correct option. Review communication techniques for the client who is delusional if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Communication, Cognition-Psychosis Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 70.ID: 9476858618 A nurse develops a plan of care for a depressed client who is complaining of feelings of hopelessness and helplessness. Which interventions should the nurse include? Select all that apply. A. Assisting the client in identifying sources of hope Correct B. Frequently engaging in superficial social discussions C. Giving the client time to respond during communication Correct D. Avoiding talking about serious issues that might further depress the client E. Offering simple activities that provide the client an opportunity to be successful Correct Rationale: The nurse should establish rapport by sharing time and offering supportive companionship. The nurse should assist the client in identifying source of hope and give the client time to respond. Successful accomplishment of simple activities will help the client achieve a sense of success. Superficial and social discussions are not helpful. Avoiding serious issues is a social rather than a therapeutic approach and may further depress the client. Remember, the client is working through depression. Negative issues should be discussed so that the client may explore effective coping skills. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques and the care of the client with depression. Note that the correct options focus on the client’s needs and feelings. Review these interventions if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Caregiving, Mood and Affect HESI Concepts: Caregiving, Mood and Affect Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 260-261)1. St. Louis: Saunders. Awarded 3.0 points out of 3.0 possible points. 71.ID: 9476861008 A nurse plans care for a client with an obsessive-compulsive disorder (OCD). Which nursing intervention should receive priority? A. Monitoring the client for abnormal behaviors B. Establishing a trusting nurse-client relationship Correct C. Educating the client about self-control techniques D. Encouraging participation in daily self-care activities Rationale: Establishment of a trusting nurse-client relationship is the foundation for giving effective nursing care to the client with a mental health disorder. The nursing interventions identified in each of the other options may be appropriate but are not the priority. Test-Taking Strategy: Note the strategic word “priority.” This tells you that there may be more than one correct option and that you must determine which one is most important. Use knowledge of principles of mental health nursing to identify the correct option. Review these principles if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Caregiving, Coping HESI Concepts: Professional Behaviors/Professionalism, Stress and Coping – Caregiving Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 228, 231). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 72.ID: 9476861046 A client with a panic disorder has been medicated with alprazolam.Which assessment finding suggests that the client is experiencing a side effect of the medication? A. Confusion Correct B. Increased anxiety C. Heightened alertness D. Enhanced coordination Rationale: Alprazolam is an antianxiety agent (benzodiazepine) used in the short-term management of panic disorder. Central nervous system side effects include disorientation, confusion, drowsiness, and clumsiness. Increased anxiety is not a side effect of the medication. The medication can cause both physical and psychological dependence, so it is used with caution. Test-Taking Strategy: Use the process of elimination. Focusing on the subject, a side effect, will direct you to the correct option. Also, note that options that are comparable or alike (increased anxiety, heightened alertness, enhanced coordination). If this question was difficult, review the side effects of this medication. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Assessment, Safety Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 44) St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 73.ID: 9476861069 A client experienced the sudden onset of blindness, but extensive testing revealed no organic reason that the client could not see. The nurse later learned that the blindness developed after the client witnessed a fire at a neighboring house in which the family of three died. Which problem should the nurse suspect? A. Psychosis B. Repression C. Conversion disorder Correct D. Dissociative disorder Rationale: A conversion disorder is an alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is often an expression of a psychological need or conflict. Psychosis is a state in which a person’s mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person’s capacity to deal with life demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Test-Taking Strategy: Focus on the data in the question. Noting that there is no organic reason to account for the blindness will direct you to the correct option. If you had difficulty with this question, review the conditions identified in the options. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Priority Concepts: Content Area: Mental Health Giddens Concepts: Clinical Judgment, Coping HESI Concepts: Clinical Decision-Making/Clinical Judgment, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 201). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 74.ID: 9476855992 A mental health nurse finds a client in the hospital day room self-inflicting cigarette burns. After removing the cigarette and attending to the burns, what is the nurse’s next action? A. Restraining the client B. Putting the client in a seclusion room C. Instituting one-on-one nursing supervision Correct D. Calling the psychiatrist and reporting the incident Rationale: Safety is the nurse’s first priority. When a client inflicts harm on him- or herself, immediate one-on-one nursing supervision should be instituted. Next, the psychiatrist should be notified regarding the incident. The client should not be restrained or placed in seclusion, because these actions violate the client’s rights. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Note that the question asks for the nurse’s next action. Because the question indicates that the client’s physiological needs have been met, select the option that addresses a safety need. The correct option is the one that would meet the safety needs of this client without infringing on the client’s rights. Review nursing interventions for the client at risk for self-harm if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Interpersonal Violence, Safety HESI Concepts: Safety, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 453). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 75.ID: 9476840184 A client is unwilling to leave the house for fear of doing “something bizarre in public.” As a result, the client remains homebound except when accompanied by her husband. The nurse analyzes this data and determines that the client is experiencing: A. Agoraphobia Correct B. Social phobia C. Hypochondria D. Claustrophobia Rationale: Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in a reduction in social and professional interactions. Social phobia is focused more on a specific situation, such as the fear of speaking, performing, or eating in public. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. Claustrophobia is a fear of closed-in places. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and recall the behavior associated with the various types of phobias to answer this question. If you had difficulty with this question, review phobia types and associated client behaviors. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Anxiety, Coping HESI Concepts: Mood and Affect – Anxiety, Stress and Coping Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 177). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 76.ID: 9476841863 A client states to a nurse, “I feel like putting an end to my misery." How should the nurse respond to the client? A. "Why do you feel like that?" B. "We all feel like that sometimes." C. "Tell me more about what you feel like doing." Correct D. "You feel like that now, but soon you'll get your will to live back." Rationale: All suicidal threats must be taken seriously, and their meaning must be thoroughly explored. Clichés and false reassurance block communication and devalue the client. “Why" questions request an explanation from the client when the client may not have one. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. Remember, encourage the client to express his or her feelings. If you had difficulty with this question, review therapeutic communication techniques. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Safety HESI Concepts: Communication, Safety Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 452). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 77.ID: 9476835351 A nurse uses the proverb "People in glass houses shouldn’t throw stones” to assess the abstract thinking ability of a client with schizophrenia. Which response by the client demonstrates that the capacity for abstract thinking is intact? A. "Don’t throw stones." B. "I don’t live in a glass house." C. "The windows will break if you throw stones." D. "I shouldn’t tell someone not to do something that I’m doing myself." Correct Rationale: Abstract thinking is the ability to discern meaning from a situation. Responses from a client with schizophrenia may be inappropriate because the client interprets words literally (concretely) rather than abstractly. Clients with schizophrenia often have difficulty with concreteness and symbolism. The incorrect options are indicative of concrete thinking and do not reflect an ability to think abstractly. Test-Taking Strategy: Use the process of elimination. Focus on the response that indicates that the client perceives relationships accurately and is thinking abstractly. The correct option indicates that the client is able to abstract meaning from the old saying. Review the manifestations associated with schizophrenia if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Clinical Judgment, Cognition HESI Concepts: Assessment, Cognition Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 349-350). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 78.ID: 9476852008 Amitriptyline hydrochloride has been prescribed for a client with depression, and the nurse provided medication instructions. Which statements by the client indicate that the teaching was effective? Select all that apply. A. “It’s important for me to avoid cheese products.” B. “I can chew sugarless gum if my mouth feels dry.” Correct C. “This medicine will stop my depression immediately.” D. “This medication may make it hard for me to fall asleep.” E. “I’m allowed to eat prunes every other day to prevent constipation.” Correct Rationale: Amitriptyline is a tricyclic antidepressant. It has anticholinergic effects, including dry mouth and constipation. Sugarless gum and high-fiber foods may produce relief from these side effects. This medication has sedative effects, so a single maintenance dose is usually taken at bedtime. All of the other client statements regarding this medication indicate misinformation on the part of the client. It will take several weeks for the client to experience relief from depression. Selected cheese products should be avoided by the client taking monoamine oxidase inhibitors (MAOI) antidepressants, not tricyclics. Test-Taking Strategy: Focus on the name of the medication. Specific knowledge regarding this medication and recalling that amitriptyline is a tricyclic antidepressant will assist in answering correctly. If you are unfamiliar with this medication, review this content. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 541). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 79.ID: 9476840119 A nurse reviews assessment data for a client admitted to the mental health unit and notes that that the client is experiencing anxiety because of a situational crisis. Which event could cause this type of crisis? A. Loss of a job Correct B. Recent sexual assault C. Witnessing a fatal automobile accident D. Destruction of the client’s home by a hurricane Rationale: A situational crisis arises from external rather than internal sources. Situations that could precipitate this type of crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, the addition of new family members, pregnancy, and severe illness. Recent sexual assault, witnessing a fatal automobile accident, and destruction of one’s home by a hurricane are all examples of adventitious crises Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they identify adventitious crises. If you had difficulty with this question, review the types of crises. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Anxiety, Clinical Judgment HESI Concepts: Anxiety. Assessment Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 183). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 80.ID: 9476850782 A nurse develops a plan of care for a client with a diagnosis of posttraumatic stress disorder. Which goal for the client is appropriate? A. Reporting a decrease in nightmares Correct B. Decreasing the time spent performing ritualistic behaviors C. Reframing anxiety-provoking situations D. Exerting more control over intrusive thoughts and rituals Rationale: Appropriate goals for the client with posttraumatic stress disorder include reporting an increase in restful sleep periods and a decrease in nightmares or flashbacks. Decreased time spent in ritualistic behaviors and increased control over intrusive thoughts and rituals are appropriate goals for clients with obsessive-compulsive disorder. Reframing anxiety-provoking situations is an appropriate goal for a client with a phobia. Test-Taking Strategy: Use the process of elimination. Focusing on the client’s diagnosis and recalling the characteristics of this disorder will direct you to the correct option. Review appropriate goals for the client with posttraumatic stress disorder if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Caregiving, Coping HESI Concepts: Professional Behaviors/Professionalism, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 182). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 81.ID: 9476852089 A nurse reviews the laboratory results of a client taking lithium carbonate. Which serum electrolyte value would the nurse identify as a precipitating factor for lithium toxicity? A. Sodium 130 mEq/L (130 mmol/L) Correct B. Sodium 145 mEq/L (145 mmol/L) C. Calcium 8.4 mg/dL (2.1 mmol/L) D. Calcium 10.2 mg/dL (2.55 mmol/L) Rationale: Sodium depletion decreases the renal excretion of lithium, thereby causing the medication to accumulate and become toxic. The client should be instructed to maintain a normal sodium intake. The normal sodium level ranges from 135 to 145 mEq/L (135-145 mmol/L). The normal calcium level is 8.2 to 10.2 mg/dL ( 2.15-2.55 mmol/L). The sodium of 145 mEq/L and the calcium levels identified in the options are all normal values. Test-Taking Strategy: Focus on the subject, a precipitating factor for lithium toxicity. The correct option is the only abnormal value. Also, recall that sodium depletion can lead to lithium toxicity. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Pharmacology Giddens Concepts: Cellular Regulation, Clinical Judgment HESI Concepts: Cellular Regulation, Clinical Decision-Making/Clinical Judgment References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 709-711) St. Louis: Saunders. Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 547). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 82.ID: 9476835342 A client with a personality disorder will begin recreational therapy as a component of the treatment plan. This treatment modality is mosthelpful for clients who: A. Are angry B. Have difficulty socializing Correct C. Tend to become violent toward others D. Become “numb” when experiencing intense feelings Rationale: Recreational therapy helps clients with personality disorders explore ways to enjoy themselves without the use of self-destructive behaviors such as the abuse of alcohol or drugs. This modality is helpful to clients who have difficulty socializing, because recreation strengthens social skills. Art therapy may be helpful for a client with anger issues. The client who is exhibiting violent behavior may require medication therapy. Movement therapy may be helpful for clients who become “numb” when experiencing intense feelings. Test-Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (angry and violent tendencies). To select from the remaining options, think about the purpose of recreational therapy, which should direct you to the correct option. If you had difficulty with this question, review the purpose of recreational therapy. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Coping HESI Concepts: Clinical Decision-Making/Clinical Judgment, Coping and Stress Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 642-643). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 83.ID: 9476861035 A nurse monitors a client in seclusion. The client calmly says to the nurse, "I’m no longer a threat to myself or others." The nurse interprets this statement as an indication that the client may be: A. Manipulating the nurse B. Ready to come out of seclusion Correct C. Ready to perform self-care activities Incorrect D. Needing to communicate and socialize with others Rationale: When the client demonstrates calm behavior and communicates he or she is no longer a threat to self or others, the nurse gathers additional assessment data to determine whether it is safe for the client to come out of seclusion. There is no relationship between the client’s statement and the nurse interpreting that the client is manipulating the nurse, ready to perform self-care activities, and needing to communicate and socialize with others. Test-Taking Strategy: Note the strategic word “calmly” and focus on the client’s statement. Use the process of elimination and Maslow’s Hierarchy of Needs theory to identify the correct option. Review seclusion procedures if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 588). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 84.ID: 9476840178 A nurse receives a telephone call from a client who states, “I’m going to kill myself, and I have a loaded gun in my lap.” The nurse should first: A. Obtain the client’s name and address B. Tell the client, “You are making a big mistake.” C. Ask the client whether there is a neighbor close by D. Keep the client talking and encourage her to express her feelings Correct Rationale: In a crisis, the nurse must take an authoritative, active role to promote the client’s safety. A loaded gun in front of a client who verbalizes suicidal intent is a crisis. The client’s safety is of prime concern. Keeping the client on the phone and encouraging her to express her feelings is the best first action. Once a rapport has been established with the client, the nurse can ask the client for her name and address so help can be provided. Taken prematurely, this action could anger the client, causing her to hang up. Telling the client that she is making a big mistake and asking whether there is a neighbor close by are inappropriate and could also anger the client, causing her to hang up. Additionally, the incorrect options do not address the client’s thoughts and feelings. Test-Taking Strategy: Use the process of elimination, focusing on the subject, the client’s safety. The correct option is the umbrella option that most directly addresses safety of the client. Review care to the suicidal client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Interpersonal Violence, Safety HESI Concepts: Safety, Violence Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 195). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 85.ID: 9476855967 A nurse monitors a depressed adolescent who may be suicidal. Which behavior indicates that the client is at high risk for suicide? A. Refusing to communicate B. Attempting to manipulate others C. Arguing with family members when they visit D. Giving a cherished book of poems to another client Correct Rationale: A depressed, suicidal client often gives away that which is of value to him or her as a way of saying goodbye and wanting to be remembered. Refusing to communicate, attempting to manipulate others, and continually arguing with family members when they visit are often typical of any adolescent. Test-Taking Strategy: Use the process of elimination and focus on safety. The correct option is an action that could indicate that the client is saying goodbye. Review behaviors that indicate suicidal intent if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 451). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 86.ID: 9476858675 A client prepares to attend an Alcoholics Anonymous meeting for the first time. Which step, the first in the 12-step program, should the nurse discuss with the client? A. Admitting to having a problem Correct B. Stating that drinking will be stopped C. Discontinuing relationships with friends who drink D. Identifying activities that can be substituted for drinking Rationale: The first step in the 12-step program is admitting that a problem exists. Stating that drinking will stop and discontinuing relationships with friends who drink are unrealistic as first steps in the process to recovery. Although identifying healthy alternatives to drinking may be a useful strategy, it is not the first step. Test-Taking Strategy: Use the process of elimination. Note the strategic words “first step” in the question. This will direct you to the correct option. If you are unfamiliar with 12-step programs, review this content. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Addiction, Caregiving HESI Concepts: Behaviors-Addiction, Caregiving Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 467). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 87.ID: 9476861023 A client with mania is placed in seclusion after an outburst of violent behavior that includes physically assaulting another client. As the client is secluded, the nurse should: A. Ask, “Do you understand why seclusion is necessary?” B. Remain silent, because verbal interaction would be too stimulating C. Tell the client, “You will be allowed to rejoin the others when you can behave” D. Inform the client, “You are being secluded to help you regain control of yourself” Correct Rationale: The client is removed to a nonstimulating environment because of his or her behavior. It is best to inform the client directly of the purpose of the seclusion. Remaining silent because verbal interaction would be too stimulating, telling the client he or she is not allowed to rejoin the others until able to behave, and asking the client whether he or she understands why the seclusion are all nontherapeutic approaches. Not letting the client rejoin the others also implies punishment. Test-Taking Strategy: When answering a question as described, look for the option that presents reality most clearly to the client. The correct option is the only one that provides a clear and direct purpose for the seclusion. Review care of a client placed in seclusion if you have difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Caregiving, Safety HESI Concepts:Cargiving, Safety Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 588). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 88.ID: 9476835366 A client with severe depression tells the nurse, “I’m feeling much better now.” The client demonstrates increased interaction and energy levels. The nurse implements one-on-one supervision because the behavior indicates that the client: A. Is an elopement risk B. Needs interpersonal support at this time C. Needs reinforcement of positive behaviors D. Now has the energy to carry out a suicide plan Correct Rationale: The client now has the energy to act on a suicide plan. Suicidal clients may appear to be feeling better immediately before making an attempt. Some clients experience a feeling of relief when the decision to commit suicide has been made and plans have been finalized. An elopement risk, a need interpersonal support, and a need for reinforcement of positive behaviors are incorrect interpretations of the client’s behaviors. Test-Taking Strategy: Focus on the data in the question. Use Maslow’s Hierarchy of Needs theory to direct you to the correct option. Also note the relationship between the client’s diagnosis and the words “suicide plan” in the correct option. If you had difficulty with this question, review nursing content regarding suicide. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Analysis Content Area: Mental Health Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Assessment, Safety Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 453). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 89.ID: 9476858681 A woman arrives at the emergency department accompanied by her husband, seeking care for cuts to her eye and multiple contusions. The client has been in the emergency department numerous times for similar injuries and the nurse suspects that the husband is inflicting the injuries. Which action should the nurse take? A. Confronting the husband with these suspicions B. Saying to the husband, "What’s your story this time?" C. Saying to the client, "Are you planning to divorce soon?" D. Taking the client to a private area to conduct the interview Correct Rationale: Client safety is the most important consideration for the nurse. Taking the client to a private area is essential, because the husband is battering the client she is unlikely to be truthful about her injuries in his presence. Some women are fearful of being harmed by the partner or want to protect the partner. Confronting the husband is incorrect because it is the nurse's responsibility to support the client in making an appropriate decision, not to make it for her. Asking the client whether she is planning to divorce is not an example of therapeutic communication, and the client is unlikely to be truthful in the presence of the husband. Challenging the husband might cause him to take his wife away or not bring her next time she needs care. Test-Taking Strategy: Use the process of elimination. Focusing on the subject of client safety will direct you to the correct option. Also, use of therapeutic communication techniques will direct you to the correct option. Review care of the battered woman if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 425). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 90.ID: 9476835380 A client says to the nurse, "I’m divorced and my children live in other parts of the country. They never visit or phone me. I feel so lonely. No one would notice if I were gone." The nurse should make which response to the client? A. "You should find new interests." B. "Have you considered an online dating service?" C. "Try to take a more cheerful outlook. Behind every cloud is a silver lining." D. "Things seem very bleak to you right now. Are you thinking of harming yourself?" Correct Rationale: The nurse is responsible to clarify the client's statement, even though it is a passive one of low lethality. In the correct option, the nurse uses the therapeutic communication technique of focusing and questioning. This option also allows the nurse to assess the suicidal ideation passively expressed by the client. Giving advice is a nontherapeutic communication technique that does not allow the nurse to assess the potential for suicide. The incorrect options, respectively, are directive, judgmental, and falsely reassuring. (Also, the “silver lining” comment is a cliché. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the options that are comparable or alike in that they ignore the client’s concerns or give advice. Remember to address the client’s feelings. Review therapeutic communication techniques if you have difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Caregiving HESI Concepts: Communication, Gried and Loss Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 91.ID: 9476855976 A nurse works during the evening shift. Which actions should be performed for a client who will undergo electroconvulsive therapy (ECT) on the next day? Select all that apply. A. Helping the client reduce anxiety about the procedure Correct B. Restricting visitors and limiting participation in unit activities C. Discussing the risks and benefits of and alternatives to ECT with the client D. Having the client shampoo and dries her hair, cleaning it of all hairspray and creams Correct E. Implementing nothing-by-mouth (NPO) status for 12 to 16 hours before the procedure Rationale: The nurse should help reduce any anxiety the client might have with regard to the procedure. The client should shampoo and dry her hair the night before ECT treatment and not use hairsprays or creams before ECT to reduce the risk of burns. Restricting visitors or participation in unit activities is unnecessary. The client is kept NPO for 6 to 8 hours before treatment. Discussion of the risks, benefits, and alternatives to ECT is the responsibility of the healthcare provider when obtaining the client’s informed consent. Test-Taking Strategy: Read each option carefully. Thinking about the purpose of the procedure and how this procedure is performed will direct you to the correct options. Review the preparations for ECT if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cargiving Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 596-597). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 92.ID: 9476855921 A client admitted to the mental health unit with depression is unclean, has body odor, and is inappropriately dressed. An accompanying family member is embarrassed about the client’s appearance. When planning care, it is most important for the client and family member to understand that: A. Client self-esteem needs take priority over appearance B. Hygiene is not important to those who socially isolate themselves C. The nurse will help the client meet hygiene needs until the client is able to do so Correct D. Group peer pressure on the unit will soon have the client attending to hygiene needs Rationale: Both the client and family need to know that the nurse will assist the client until is able to resume self-care activities. A client with depression has decreased energy and is subject to psychomotor retardation, so, assistance is necessary. Indicating that self-esteem needs to take priority over appearance, that hygiene is not important, and that peer pressure will soon have the client attending to hygiene needs are all incorrect conclusions. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. The correct option addresses the physiological needs of the client in a supportive manner. Review care of the client with depression if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Caregiving, Functional Ability HESI Concepts: Caregiving, Health, Wellness, and Illness – Functional Ability Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 262). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 93.ID: 9476858660 A depressed client tells the nurse, “I’m powerless, and I’m not worthy of having friends. Sometimes I take too many pills.” The nurse’s priority in planning care for this client is: A. Continual assessments for suicidal ideation Correct B. Providing structured activities with other clients C. Acknowledging the client’s accomplishments to build self-esteem D. Monitoring the effects of the prescribed antidepressant medication Rationale: Client safety always takes priority over other nursing care concerns. Therefore the nurse should continually assess the client for suicidal ideation. The other options are correct nursing measures for a depressed client, but they are not the priority. Test-Taking Strategy: Use the process of elimination. Note the words “I take too many pills.” The potential for suicide has the highest priority. Review the priorities of care for the client at risk for suicide if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Interpersonal Violence, Safety HESI Concepts: Safety, Violence Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 255). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 94.ID: 9476861085 A client with obsessive-compulsive disorder is hospitalized because his ritualistic behaviors have become so time-consuming that the client is unable to maintain employment. The initial priority nursing intervention is to: A. Provide the client with the unit rules B. Assist the client in carrying out the rituals C. Allow the client time to perform the rituals Correct D. Confront the client about his poor use of time Rationale: Compulsive rituals are used to manage the client’s anxiety, even though the behavior is maladaptive. It is usually not helpful to interfere prematurely with a ritual unless it threatens the client’s health. Providing the client with unit rules, assisting the client in carrying out rituals, and confronting the client about poor use of time are not therapeutic interventions and would increase the client’s anxiety. Test-Taking Strategy: Use the process of elimination, focus on the client’s diagnosis, and note the strategic word “initial.” It is initially important to allow the client to perform rituals to control the client’s anxiety. If you are unfamiliar with obsessive-compulsive disorders, review this content. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Anxiety, Coping HESI Concepts: Mood and Affect – Anxiety, Stress and Coping – Caregiving Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 230-231). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 95.ID: 9476844096 A client who recently witnessed a murder says, “I feel like I’m losing my mind. I keep hearing the gunshots and seeing the victim lying on the ground.” In light of the client’s statement, the nurse should: A. Teach the client relaxation techniques B. Encourage the client to think about happy events C. Support the client in talking about the event and related feelings Correct D. Ask the healthcare provider to prescribe an antianxiety medication Rationale: It is most important to support the client to talk about the event and feelings related to it. Teaching the client relaxation techniques may be helpful at some point, but the client must first express his feelings about the experience. Trying to distract the client from thinking about the event or asking the healthcare provider to prescribe an antianxiety medication does not respond to the client’s needs. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Eliminate the options that do not encourage further discussion about the client’s feelings. Teaching the client how to relax will be helpful at some point, but not in the beginning of the therapeutic relationship. Remember to address client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Anxiety, Coping HESI Concepts: Mood and Affect – Anxiety, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 96.ID: 9476844066 A client compulsively makes and remakes the bed numerous times and often misses breakfast and some morning activities because of this ritual. Which nursing action is appropriate? A. Expressing tactful, mild disapproval of the behavior B. Helping the client make the bed so that the task is finished sooner C. Teaching the client about the neurotransmitters involved in compulsive behavior D. Offering reflective feedback such as “I see you made your bed several times. That takes a lot of energy.” Correct Rationale: Reflective feedback lets the client know that the nurse acknowledges the behavior and understands that it can be very tiring. Verbalizing even tactful disapproval would increase the client’s anxiety and reinforce the need to perform the ritual. Helping with the ritual is nontherapeutic and reinforces the behavior. Teaching the client about the role of neurotransmitters in compulsive behavior does not focus on the client’s feelings. Test-Taking Strategy: Use the process of elimination. Recalling that the purpose of the ritual is to relieve anxiety will assist you in eliminating the incorrect options, because these actions would increase the anxiety. Review care of the client with obsessive-compulsive disorder if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Anxiety, Caregiving HESI Concepts: Mood and Affect – Anxiety, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 181). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 97.ID: 9476850796 A client with paranoid schizophrenia has been agitated, threatening and shouting at others, and refusing to participate in therapy. Projection and denial are evident in these behaviors. The appropriate nursing action is to: A. Accept the behavior without comment B. Explore past experiences of acting out with the client C. Collect information from the client to develop a database D. Acknowledge the client’s anxiety and then set limits on the behavior Correct Rationale: Denial is a failure to recognize what is occurring in a situation and generates inappropriate behavior. Projection involves attributing an attitude, behavior, or impulse to someone else. Setting limits on unacceptable and inappropriate behaviors in a nondefensive manner is most appropriate in this situation. It also helps ensure the safety of others. Accepting the behavior without comment, exploring past experiences of acting out with the client, and collecting information from the client to develop a database do not provide interventions that directly relate to the client’s behavior, Test-Taking Strategy: Use the process of elimination and note the behaviors of the client identified in the question. These behaviors require intervention by the nurse. The correct option is the only one that specifically provides client intervention. Review care of the client with paranoid schizophrenia and the potential for violence if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 320). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 98.ID: 9476852032 A home care nurse visits a depressed older adult client in whom type 2 diabetes mellitus was recently diagnosed. As the nurse teaches about insulin injections, the client says, “I don’t think I’ll ever learn to stick this needle in myself.” Which response by the nurse is therapeutic? A. “With proper diet and exercise, you may be able to stop taking insulin.” B. “Perhaps you could start by telling me what troubles you most about injecting yourself.” Correct C. “Injecting yourself with insulin seems odd at first. Let me show you how to assemble your insulin pen.” D. “All of my clients tell me that when they first start to self-administer insulin, but they learn. You will, too.” Rationale: In listening to the client’s fears, the nurse allows the client to vent, establishes a one-on-one relationship, and identifies areas in which the client will require emotional support. It may not be possible for the client to discontinue insulin, regardless of his compliance with the prescribed diet and exercise. The nurse should not begin teaching until the client is able to accept the need for injections. Clichés and false reassurances are nontherapeutic responses that minimize the client’s feelings and risk belittling the client. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Focus on the client’s feelings. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Teaching and Learning Content Area: Mental Health Giddens Concepts: Caregiving, Coping HESI Concepts: Professional Behaviors/Professionalism, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 99.ID: 9476853908 A nurse is caring for a client with a phobia who is to be treated with systematic desensitization. The nurse, explaining this form of behavior modification to the client, and tells the client that the therapy: A. Involves the use of medication Incorrect B. Encourages self-control in the client C. Involves the use of a positive stimulus to avoid the negative stimulus D. Involves exposing the client for short periods to the phobic object while the client is in a relaxed state Correct Rationale: Systematic desensitization is a form of therapy used for some clients with phobias. The client is introduced, in short periods of exposure, to the phobic object while in a relaxed state. Gradually exposure is increased until the anxiety about or fear of the object or situation has ceased. Using medication, encouraging self-control, and using a positive stimulus to avoid the negative stimulus are incorrect because they do are not focused on helping the client cope with the phobia. Test-Taking Strategy: Use the process of elimination. Note the relationship between the words “systematic desensitization” in the question and “exposing the client for short periods” in the correct option. This should assist you in identifying the correct option. If you had difficulty with this question, review systematic desensitization. Level of Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Teaching and Learning Content Area: Mental Health Giddens Concepts: Anxiety, Coping HESI Concepts: Mood and Affect – Anxiety, Stress and Coping – Caregiving Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 30). St. Louis: Saunders. Awarded 0.0 points out of 1.0 possible points. 100.ID: 9476852050 A visitor brings a wrapped gift to a suicidal client under one-on-one suicide precautions. Which action should the nurse take? A. Asking the client to open the gift Correct B. Reinforcing the safety policies with the client C. Telling the client what a beautiful package it is D. Letting the visitor spend time alone with the client Rationale: The nurse must be concerned with the safety of the client. The visitor may or may not be aware of the client’s suicidal thoughts or the hospital’s safety policies. The client should open the gift in the presence of the nurse so that sharp or unsafe objects may be locked in the client’s safety box. Reinforcing the safety policies with the client, telling the client what a beautiful package it is, and letting the visitor spend time alone with the client are all inappropriate interventions that do not help ensure the client’s safety. Test-Taking Strategy: Use the process of elimination and note that the client is suicidal. Because the client’s safety is the priority, the only option that allows the nurse to ensure that the gift does not contain items that may be dangerous for the client is the correct option. Review suicide precautions if you have difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 452-453). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. [Show More]

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