Alterations in Behavior

43問 • 1年前

問題一覧

A client who is in a four-bed room since admission becomes extremely anxious and is having difficulty sleeping. What is the nurse’s best response?

“I’m going to move you to a private room.”

During an assessment interview the client relates experiencing overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude the client is experiencing?

Narcolepsy

A client tells a nurse, “I have been having trouble sleeping and feel wide awake as soon as I get into bed.” Which strategies should the nurse teach the client that will promote sleep? Select all that apply.

Leave the bedroom if you are unable to sleep., Exercise in the afternoon rather than in the evening., Count backward from 100 to 0 when your mind is racing

A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client’s history may be the cause of this disorder? Select all that apply.

Chronic stress, Excessive caffeine, Environmental noise

An adolescent is admitted to the psychiatric service in stable physical condition with the diagnosis of anorexia nervosa. The adolescent has lost 20 pounds in 6 weeks and is very thin but is excessively concerned about being overweight. What is the most important initial nursing intervention?

Attempt to establish a trusting relationship with the adolescent.

What is an appropriate behavior modification goal for a client with anorexia nervosa?

Gain 1 pound of weight a week.

Evaluation of clients with anorexia nervosa requires reassess- ment of behaviors after admission. Which finding indicates that the therapy is beginning to become effective?

Weight gain of six pounds since admission 3 weeks ago

A cachectic adolescent with the diagnoses of anorexia nervosa, dehydration, and electrolyte imbalances is admitted to a mental health facility. The adolescent has been obsessed with weight, has exercised for hours every day, has taken enemas and laxatives several times a week, and has engaged in self-induced vomiting. Which is a priority when a nurse plans care for this client?

Correcting electrolyte imbalances

A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa?

Has behaviors and an appearance that appear appropriate

What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa?

Based on realistic limits

A college student is brought to the mental health clinic by the parents. The diagnosis is borderline personality disorder. Which factors in the client’s history support this diagnosis? Select all that apply.

Impulsiveness, Lability of mood, Self-destructive behavior

A hospitalized client who was diagnosed with a borderline personality disorder consistently breaks the unit’s rules. How will confronting the client about this behavior help the client?

Becomes more self-aware

A client with a personality disorder tells a nurse, “I want to tell you something, but you must promise to keep it a secret.” Which response could lead to splitting among the staff?

“Your comments will be kept confidential because I am your advocate.”

A nurse is working in the orientation phase of a therapeutic relationship with a client who has borderline personality disorder. What will be most difficult for the client at this stage of the relationship?

Setting mutual goals for the relationship

The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate response by the nurse?

Inform the client in a matter-of-fact tone that everyone must remain with the group.

An adult is diagnosed with schizotypal personality disorder. How should a nurse describe the client’s behavior?

Introverted and emotionally withdrawn

A nurse begins a relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action?

Respect the client’s need for social isolation.

A client has the diagnosis of histrionic personality disorder. Which behavior should the nurse expect when assessing this client?

Extroverted and dramatic

A client with a borderline personality disorder receives the wrong meal tray for lunch and angrily states, “The next time I see the dietician, I am going to throw this tray at her!” What is the nurse’s most appropriate response?

Tell the client it is frustrating not to get the correct tray, but throwing the tray at the dietician is unacceptable behavior.

Which nursing intervention is most important for a client who has the diagnosis of antisocial personality disorder?

Provide clear boundaries and consequences.

A nurse is caring for a client with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care?

Usually is unable to postpone gratification

The nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care?

Exhibits lack of empathy for others

A client with a diagnosis of antisocial personality disorder is being discharged from the hospital. The client asks the nurse, “Can I have your phone number so that I can call you for a date.” What is the nurse’s best response?

“Our relationship is professional; therefore, I will not see you socially.”

A nurse identifies that a client is pretending to be ill. What does this behavior usually indicate?

Malingering

A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down to talk. The client requesting the nurse’s attention is manipulative and uses acting-out behaviors when demands are unmet. How should the nurse intervene?

Tell the interrupting client, “I’ll be back to talk with you after I orient this new client.”

A client is diagnosed with an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client’s primary problem?

Low self-esteem

What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol?

Motivational readiness

A client with a history of alcoholism is diagnosed with Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?

Intramuscular injections of thiamine

A client with an alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse’s initial reply?

“No, I don’t see any bugs.”

A recovering alcoholic joins Alcoholics Anonymous (AA) to help maintain sobriety. What type of group is AA?

Self-help group

Clients addicted to alcohol often use the defense mechanism of denial. What is the reason why this defense is so often used?

Reduces their feelings of guilt

What should a nurse conclude that a client is doing when making up stories to fill in blank spaces of memory?

Confabulating

A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism?

Active membership in Alcoholics Anonymous

A nurse uses the CAGE Screening Test for Alcoholism to determine the potential an individual has for a drinking problem. Which is one of the four questions included in this test?

“Have you ever felt bad or guilty about your drinking?”

A client undergoing alcohol detoxification asks about attending Alcoholics Anonymous (AA) meetings after dis- charge. What is the nurse’s best initial reply?

“What feelings do you have about going to those meetings?”

While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client’s spouse about the purpose of AA. What is the priority goal of this self-help group?

Change destructive behavior.

A client who has just begun attending Alcoholics Anonymous (AA) asks a nurse how important it is to attend meetings regularly. What is the nurse’s best response?

“Do you think that attending these meetings may not be helpful?”

A client with a long history of alcohol dependence spends 28 days in an alcohol rehabilitation unit. What type of referral does the nurse anticipate will be included in the discharge plan?

Community-based self-help group

What behavior by a client with a long history of alcohol abuse is an indication that the client may be ready for treatment?

Verbalizing an honest desire for help

A nurse is interviewing a client newly admitted to an out- patient program after withdrawal from alcohol. What behavior best indicates that the client has accepted that drinking is a problem?

Attends Alcoholics Anonymous meetings daily

A client who is a polysubstance abuser is mandated to seek drug and alcohol counseling. What is an appropriate initial outcome criterion for this client?

“Verbalizes that a substance abuse problem exists.”

A nurse is caring for a client who is addicted to opioids and who had a major surgery. The client is receiving methadone. What is the purpose of this medication?

Converts opioid use from an illicit to a legally controlled drug

A client who is addicted to opioids had emergency surgery. During the postoperative period the health care provider decreases the previously prescribed methadone dose. For what clinical manifestations should a nurse monitor the client?

Agitation and attempts to escape from the hospital

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS