PSYCHIA POST TEST

189問 • 1年前

Kyla Angelique Son

通報

問題一覧

The nurse will probably spend more time on the orientation phase of the nurse-patient relations with which patient?

The highly distrustful teenager who ran away from an abusive home situation

When the client sits 12 feet away from the nurse during the assessment interview, the client views the nurse as a:

Stranger

A child's parent enters the nurse's station yelling, "What is wrong with you people? My daughter cut herself and you allowed it to happen. I thought my child would be safe here." Select the assertive response for the nurse.

"I can't hear you if you're yelling. Let's sit down and talk about it."

When a patient discloses a history of chronic trauma to the nurse, what therapeutic response should the nurse provide?

"This is difficult to talk about; I'm here to help."

A patient in an outpatient program asks the nurse, "to if he can keep this a secret." What statement best represents the nurse's most appropriate reply?

“I am not able to keep a secret, because I share our work together with the health care team here."

When considering communication, what is the initial intervention required of a nurse responsible for the care of a newly admitted patient?

Self-assessing for possible barriers to effective communication with the patient

Mr. Buko Martin states, "I'm not sure what to do. What do you think would be best?" The nurse refrains from giving advice for which of the following reasons?

It is more useful to encourage client problem-solving.

A client with paranoid schizophrenia tells the nurse, “I am here on a top secret mission for the President. Don't tell anyone I am here." Which response is most therapeutic?

“It sounds like you have some concerns about your privacy. You are safe here."

A nurse assesses a newly admitted client. Select the example of offering self.

"I'd like to spend some time helping you get comfortable talking to me."

The nurse demonstrates an understanding of the impact of physical considerations on a patient's ability to communicate effectively when implementing which intervention?

Recognizing the importance of a patient's body language

In some patients diagnosed with schizophrenia, blood flow in the frontal lobe is diminished. The nurse would expect such a patient to experience which deficit?

Inability to recall a telephone number

Which neurotransmitter is most widely associated with the biologic theory for the development of Parkinson's disease?

Dopamine

Which characteristic would support a diagnosis involving an impaired limbic system?

Lacking evidence of empathy

An adult has panic attacks. Which neurotransmitter is most implicated in this problem?

y-Aminobutyric acid (GABA)

These clients are scheduled to have magnetic resonance imaging (MRI). For which clients) should additional assessment information be gathered before the diagnostic procedure? Select all that apply

Wounds from exploding shrapnel during military service, Current complaints of extreme sensitivity to loud noises

The therapeutic milieu is an environment that is structured and maintained as an ideal, dynamic setting in which nurses can work with clients. As part of the milieu therapy, the client has the freedom to do which of the following?

Express feelings in a socially acceptable manner

The therapeutic milieu is an environment that is structured and maintained as an ideal, dynamic setting in which nurses can work with clients. Mr. Daniel Parilla with a psychotic disorder refuses to bathe or change his clothes. Which of the following interventions is congruent with the role of the nurse as a surrogate?

Assist client to bathe and change clothes

The therapeutic milieu is an environment that is structured and maintained as an ideal, dynamic setting in which nurses can work with clients. A patient experiencing a loss of reality believes in the angry voices in her head. The nurse should initially respond to a newly admitted patient who is experiencing auditory hallucinations by making which response?

"While I don't hear voices, I believe that you are."

The therapeutic milieu is an environment that is structured and maintained as an ideal, dynamic setting in which nurses can work with clients. A patient requires limit-setting by the RN. In accomplishing this intervention, what statement will the RN make?

"Here are the unit rules; let's review them."

Which intervention will best address the nursing goal of maintaining unit safety while decreasing the use of limit-setting?

As a patient's depression lessens, he or she is encouraged to engage in unit activities.

Cherry Pie Pecachu Informs the nurse that after her husband filed for annulment, she started feeling confused, helpless, and disorganized for the past 2 days. Miss Pecachu is in which crisis phase?

Initial impact

An individual calls the hospital during the night shift in crisis and is considering suicide. The nurse will begin the interaction by saying:

"Who is there with you right now?"

Juke Bones comes to the ED after being sexually assaulted. She is fearful and crying. Which intervention would be the best initially?

Conveying an attitude of acceptance and concern

A client who has experienced a tragedy states that she has attempted to use problem-solving approaches. She is exhibiting which phase of crisis?

Recoil

The capacity of human beings to cope with crisis and catastrophe in ways that are positive, and which allow them to "bounce back" to a balanced state after the crisis is referred

Resiliency

The nurse has been taking care of the client who has been taking fluphenazine (Profixin) for 2 days. The client suddenly cries out, his neck twisted to one side and his eyes appear to roll back in the sockets. The nurse finds the following PRN medications for the client. Which one should the nurse administer?

Benztropine 2 mg PO BID

For client receiving the antipsychotic medication clozapine (clozapine), what would be most important for the nurse to monitor?

Complete blood count

When the nurse checks the lithium level of a client on the unit, it is 2,0 mEq/L. What should the interpretation/action by the nurse be?

This level is high; the client should be assessed for manifestations of toxicity.

If a single dose of a drug is given and the drug has a half-life of 4 hours, what percentage of the drug will remain after 16 hours?

6.25%

When discussing pharmacokinetics, a patient experiencing gastrointestinal problems may have a problem with which process?

Absorption

A patient asks why he has been prescribed a selective serotonin reuptake inhibitor (SSRI) rather than one of the other classifications of antidepressants. The nurse addresses the patient's question best when responding:

“This classification is usually effective and generally causes fewer side effects."

When considering pharmacokinetics, what is the primary safety concern for a client prescribed lithium?

Increased risk for self-harm medication

The multidisciplinary team discusses the potential side effects of what medication prescribed to treat a patient's negative symptoms of schizophrenia?

Quetiapine

What aspect of traditional antipsychotic medication therapy is most responsible for a patient's medication nonadherence and resulting rehospitalization?

The occurrence of EPSEs.

Which breakfast selections demonstrate that a patient understands the nurse's dietary instructions while taking monoamine oxidase inhibitor (MAOI) antidepressants?

Oatmeal with almonds and milk

Progress in the nurse's understanding and use of electroconvulsive therapy (ECT) is pertinent in her practice in the psychiatric ward. The nurse understands that ECT treatments are thought to alleviate symptoms of depression by which action?

Altering serotonin levels

The nurse in the outpatient ECT clinic reviews the client's history for which of the following that might increase the client's risk during ECT?

Recent myocardial infarction

Mr. Erik Ramsey, scheduled for ECT treatment, does a correct preparation if he does which of the following?

Refraining from food and fluids for at least 8 hours before treatment

Which intervention would be the priority during the ECT Procedure?

Protecting client from falls

In the post-ECT recovery period, which finding would alert the nurse a possible problem?

Vital sign alteration

Which of the following is most likely to initiate a grief response in an individual? 1. Death of the pet dog 2. Being told by her doctor that she has begun menopause 3. Failing an exam

Death of the pet dog, Being told by her doctor that she has begun menopause, Failing an exam

Leila, who is dying of cancer, says to the nurse, "I just want to see my new grandbaby. If only God will let me live until she is born. Then I'll be ready to go." This is an example of which of Kübler-Ross's stages of grief?

Bargaining

A patient who continues to be tearful and has difficulty verbalizing feelings of sadness regarding a parent who died 11 years ago is experiencing which type of grief?

Chronic grief

Four teenagers are killed in an automobile accident. Three days later, which behavior indicates that one of the teenagers' parents is coping effectively with their loss?

Marks the site of the accident with flowers

A child dies after being struck by a car. The physician tells the parents, "Your child's injuries were so severe that there was nothing we could do." What is the initial intervention?

Stay with the parents until a support person arrives.

Depression is one of the oldest recognized psychiatric illnesses that is still prevalent today. It is so common that it has been referred to as the "common cold of psychlatric disorders." A nurse assess an elderly person for depression. Select the best question for the nurse to ask.

"How do you compare your activities and health now to 6 months ago?

A client says to the nurse, "Life doesn't have any oy How anymore. Things I once did for pleasure aren't fun." How would the nurse document this complaint:

Anhedonia

The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client with severe depression. The most reliable evaluation of outcomes will be based on

weekly weights.

A client says to the nurse, *I had my first depression after my father died about 10 years ago, but I didn't get any treatment. Now it seems even little life events cause me to get depressed again." Which theory of neurotransmission may explain this clients complaint?

Kindling may alter neuronal cell structure and function.

Which individual has the highest risk for major depression?

60-year-old man

Margaret, a 68-year-old widow, Is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Medication teaching regarding lithium is regarded as successful when the nurse hears the patient makes which statement?

"My body treats lithium just like salt."

Margaret, a 68-year-old widow, Is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. The patient who will require further teaching while on lithium would make what statement?

“I am really enjoying my aerobics dance class."

The patient refuses lithium for acute mania but is agreeable to another medication. The nurse will expect the prescriber to respond with what intervention?

Substituting the lithium with an anticonvulsant medication.

Which assessment question will the nurse ask to help identify the cause of a patient's decreased lithium levels?

"How much salt do you consume dally?"

What is the nurse's best response when asked by a patient who will begin lithium therapy, "When can I expect to see improvement in my symptoms?"

"We generally see symptom improvement in 7 to 10 days after beginning treatment."

Nurse Crispin is currently working in the community ward tending to patients with established Nurse Crispin knows that the neurotransmitter implicated as playing a part in the decision to commit suicide?

Serotonin

In their initial interview, Nurse Crispin proposes that a suicidal cilent enter into a no-suicide contract. Such a contract would contain a provision that the client promises

not to attempt suicide in the next 24 hours.

A client with a history of repeated suicidal attempts refuses to participate in a no-suicide contract but says she will try to hang on a little longer to see if hospital treatment can help her. What intensity of nursing observation should be instituted?

Constant 24-hour, one-to-one observation at arm's length

The morning after he was admitted, a suicidal client wishes to use the cordless electric razor the staff took from his suitcase the night before. Nurse Crispin should:

allow him to use the razor under staff supervision.

A suicidal individual calls a suicide hot line managed by Nurse Crispin. This represents the level of intervention classified as

Secondary

An individual calls the hospital during the night shift in crisis and is considering suicide. The nurse will begin the interaction by saying which assessment question?

"Who is there with you right now?"

Which behavior demonstrates the most lethal plan by an individual who has recently expressed suicidal ideations?

Hoarding a large number of barbiturates

Which statement is most concerning regarding a depressed client's state of mind?

"Shooting myself with dad's gun will end it all quickly."

A client has not been taking his antidepressant medication as prescribed and is admitted with suicidal ideations. The nurse demonstrates an understanding of a possible underlying cause of a client's noncompliance with the treatment plan designed to help manage his depression when

assessing the client's understanding of the risk depression presents for suicide.

The nurse is concerned that a depressed client may be displaying a nonverbal suicidal threat when he presents another client with his favorite shirt as a "gift." The nurse's Initial intervention is to:

ask the client if he is experiencing suicidal ideations with a plan to hurt himself.

A client with schizophrenia, disorganized type frequently giggles and mumbles to himself. He hasn't taken a shower for the past 3 days, presenting a disheveled, unkempt appearance. Which statement would be most appropriate for the nurse use in persuading the client to shower?

"It's time to shower. I will help you."

The nurse expects to assess which of the following in a client with diagnosis of schizophrenia, paranoid type?

Auditory hallucinations, persecutory delusions

The nurse identifies the nursing diagnosis of Disturbed Thought Processes related to exhibiting delusions of reference for a client with schizophrenia. Which outcome would be most appropriate?

Client will talk about concrete events in the environment without talking about delusions.

Which nursing response would be most appropriate when a client about hearing voices?

"I do not hear the voices that you say you hear."

During a community meeting, a client with schizophrenia begins to shout and gesture in an angry manner. Which nursing intervention would be the priority?

Maintaining safety of client and others

-You are assigned in the community ward to take care of patients with schizophrenia. The nurse documents that a client is demonstrating a negative symptom of schizophrenia when observing the client:

having difficulty focusing on any task for more than a few minutes

Which statement regarding behaviors of psychotic clients made by a float nurse requires follow-up by the mental health unit's nurse manager?

“It must be so frightening to be psychotic since no one else can understand what you are feeling."

The nurse demonstrates an understanding of the most common co-morbid condition observed in a schizophrenic individual when asking:

"Would you describe yourself as being depressed?"

Which statement made by a nurse interviewing a client who reports the fear that people are trying to poison him requires follow-up by the nurse's unit manager?

“Tell me more about how someone keeps trying to poison your food”

The nurse is confident that an individual prescribed antipsychotic medication has been experiencing medication efficacy and showing insight when he:

is able to effectively assess the reality of his thinking processes

Tony, age 21, has been diagnosed with Paranoid Schizophrenia. He has been hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the ER. The nurse is interviewing Tony. The client tilts his head to the side, stops talking midsentence, and listens intently. The nurse recognizes from these signs that Tony is likely experiencing:

auditory hallucinations.

Tony, age 21, has been diagnosed with Paranoid Schizophrenia. He has been hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the ER. Which symptom would not be assessed as a positive symptom of schizophrenia?

Affective flattening

At the psychiatric ward, Tony refuses to eat food served by the nurse. He states the voices are telling him the food is contaminated and will change him from a male to a female. A therapeutic response for the nurse would be

*I understand that the voices are very real to you, but I do not hear them."

The nurse understands that which of the following represents the primary gain experienced by a client when giving in to a compulsion?

Decrease in anxiety

For 6 weeks, Tony received an antipsychotic medication. At his clinic appointment, he tells the nurse that his hallucinations are nearly gone and that he can concentrate fairly well. She states her only problem is "the flu" that she's had for 2 days. He mentions having a fever and a very sore throat. The nurse should:

arrange for the client to have blood drawn for a white blood cell count.

A client with the diagnosis of obsessive-compulsive disorder Is admitted to the psychiatric inpatient unit for treatment when ritualistic behaviors become incapacitating. During the initial phase of treatment, which intervention would be best?

Accepting client rituals

A client with post-traumatic stress disorder has symptoms of isolation and avoidance of feelings. He states, *I know that everyone thinks that I'm cold and unfeeling and that's OK with me. I really don't need to become involved with anyone after my experiences." Which nursing diagnosis would be the priority?

Impaired Social Interaction related to self-perceived feelings of rejection by peers

The technique of exposing a client to a fear-producing sensation in a gradual manner is called:

Systematic desensitization

David, who had obsessive compulsive disorder (OCD), just returned home from work and immediately undressed and showered. As he showered, he soaped and resoaped his washcloth and rubbed it vigorously over every inch of his body. "I can't miss anything! I must get off all the germs," he kept repeating to himself. He had intended to put on clean clothes but now he wasn't sure he had gotten clean. Slowly Sam turned around, got back in the shower, and started all over again. The plan of care for David with OCD who has elaborate washing rituals specifies that response prevention is to be used. Which scenario is an example of response prevention?

Not allowing the client to wash hands after touching a "dirty" object

Antidepressants were prescribed by the physician for David. Of the following medications taken by the patient, the nurse knows that which of the following is a tricyclic antidepressant?

Clomipramine

The client tells the nurse, "I know that these headaches mean I have a serious disease like cancer. The tests are not correct, since they did not pick it up." The client has been diagnosed with hypochondriasis, which the nurse understands is characterized by which of the following?

Preoccupation with fear of serious disease

The client tells the nurse, "I know that these headaches mean I have a serious disease like cancer. The tests are not correct, since they did not pick it up." The nurse establishes which nursing diagnosis for a client with conversion disorder characterized by pain and the inability to move his left leg?

Impaired Physical Mobility related to leg pain secondary to conversion disorder

A client with somatization disorder is assessed for which of the following symptoms?

Physical symptoms for which no medical explanation exists

A client with body dysmorphic disorder is assessed for complaints of which of the following?

Preoccupation with defect

Which intervention would be most effective for a client with a somatoform disorder if the client continues to verbalize physical symptoms related to unmet dependency needs?

Limit-setting

David says to the nurse, "I've been here 4 days now, and I'm feeling better. I feel comfortable on this unit, and I'm not ill-at-ease with the staff or other patients anymore.* In light of this change, which nursing Intervention is most appropriate?

Set limits on the amount of time the client may engage in the ritualistic behavior.

A potential problem that should be investigated for David if his obsessions and compulsions get out of hand is

sleep disturbance.

Which statement indicates that the patient with an anxlety disorder has developed a healthy coping strategy for dealing with sleep difficulties?

"The student nurse taught me relaxation techniques that I will continue to use at home."

During her initial interview, Diana says to the nurse, "I can't figure out why God would let this happen to me." From this statement, the nurse assesses which of the following in Diana?

Spiritual distress

While Diana sat up In bed, a picture of the dark figure knocking her to the ground and his hands around her throat was vivid in her mind. Her heart was pounding and she was reliving it all over again, the pain and the terror of that night. It had been 2 years since she was attacked and raped in the park while jogging, but as she said "sometimes it felt like just yesterday." She had nightmares of panic almost every night. Doctors said she Is manifesting signs and symptoms of post traumatic stress disorder （PTSD）・ Diana is entering treatment for PTSD. An important facet of assessment is to:

determine use of chemical substances for anxiety relief

Diana experiences a nightmare during her first night in the hospital. She explains to the nurse that she was dreaming about that night in the park when she was raped. The nurse most appropriate initial intervention is to

stay with Diana and reassure him of his safety.

Among the following therapeutic interventions, the nurse knows that this therapy can benefit most patients with PTSD

Group therapy

Diana is experiencing a panic attack. The nurse can be Most therapeutic by

telling the client to take slow, deep breaths.

Lorraine has been diagnosed with Somatization Disorder. Which of the following symptom profiles would you expect when assessing Lorraine?

Multiple somatic symptoms in several body systems

100

Which statement about somatoform and dissociative disorders is true?

Clients lack awareness of the relations among symptoms, anxiety, and conflicts.

Astignars random QS

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Astignars random QS

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Pharma Cardio

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Pharma Cardio

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Childbearingand Women’s Health

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Childbearingand Women’s Health

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Major DisordersAffecting Women’s Health

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Major DisordersAffecting Women’s Health

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Foundations of Mental Health/Psychiatric Nursing

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Foundations of Mental Health/Psychiatric Nursing

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The Practice of Mental Health/Psychiatric Nursing

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The Practice of Mental Health/Psychiatric Nursing

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Circulatory System

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Circulatory System

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Respiratory System

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Respiratory System

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Gastrointestinal

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Gastrointestinal

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Gastrointestinal 2

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Gastrointestinal 2

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Research

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Research

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Disorders Related to Alterations in Cognition and Perception

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Disorders Related to Alterations in Cognition and Perception

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Anxiety and Alterations in Mood

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Anxiety and Alterations in Mood

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Alterations in Behavior

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Alterations in Behavior

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Neuromusculoskeletal System

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Neuromusculoskeletal System

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Communicable dx

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Communicable dx

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NP2

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NP2

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NP4

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NP4

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PALMR

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PALMR

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Sexual andGender Identity Disorders

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Sexual andGender Identity Disorders

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問題一覧

The nurse will probably spend more time on the orientation phase of the nurse-patient relations with which patient?

The highly distrustful teenager who ran away from an abusive home situation

When the client sits 12 feet away from the nurse during the assessment interview, the client views the nurse as a:

Stranger

"I can't hear you if you're yelling. Let's sit down and talk about it."

When a patient discloses a history of chronic trauma to the nurse, what therapeutic response should the nurse provide?

"This is difficult to talk about; I'm here to help."

A patient in an outpatient program asks the nurse, "to if he can keep this a secret." What statement best represents the nurse's most appropriate reply?

“I am not able to keep a secret, because I share our work together with the health care team here."

When considering communication, what is the initial intervention required of a nurse responsible for the care of a newly admitted patient?

Self-assessing for possible barriers to effective communication with the patient

Mr. Buko Martin states, "I'm not sure what to do. What do you think would be best?" The nurse refrains from giving advice for which of the following reasons?

It is more useful to encourage client problem-solving.

A client with paranoid schizophrenia tells the nurse, “I am here on a top secret mission for the President. Don't tell anyone I am here." Which response is most therapeutic?

“It sounds like you have some concerns about your privacy. You are safe here."

A nurse assesses a newly admitted client. Select the example of offering self.

"I'd like to spend some time helping you get comfortable talking to me."

The nurse demonstrates an understanding of the impact of physical considerations on a patient's ability to communicate effectively when implementing which intervention?

Recognizing the importance of a patient's body language

In some patients diagnosed with schizophrenia, blood flow in the frontal lobe is diminished. The nurse would expect such a patient to experience which deficit?

Inability to recall a telephone number

Which neurotransmitter is most widely associated with the biologic theory for the development of Parkinson's disease?

Dopamine

Which characteristic would support a diagnosis involving an impaired limbic system?

Lacking evidence of empathy

An adult has panic attacks. Which neurotransmitter is most implicated in this problem?

y-Aminobutyric acid (GABA)

These clients are scheduled to have magnetic resonance imaging (MRI). For which clients) should additional assessment information be gathered before the diagnostic procedure? Select all that apply

Wounds from exploding shrapnel during military service, Current complaints of extreme sensitivity to loud noises

Express feelings in a socially acceptable manner

Assist client to bathe and change clothes

"While I don't hear voices, I believe that you are."

"Here are the unit rules; let's review them."

Which intervention will best address the nursing goal of maintaining unit safety while decreasing the use of limit-setting?

As a patient's depression lessens, he or she is encouraged to engage in unit activities.

Cherry Pie Pecachu Informs the nurse that after her husband filed for annulment, she started feeling confused, helpless, and disorganized for the past 2 days. Miss Pecachu is in which crisis phase?

Initial impact

An individual calls the hospital during the night shift in crisis and is considering suicide. The nurse will begin the interaction by saying:

"Who is there with you right now?"

Juke Bones comes to the ED after being sexually assaulted. She is fearful and crying. Which intervention would be the best initially?

Conveying an attitude of acceptance and concern

A client who has experienced a tragedy states that she has attempted to use problem-solving approaches. She is exhibiting which phase of crisis?

Recoil

The capacity of human beings to cope with crisis and catastrophe in ways that are positive, and which allow them to "bounce back" to a balanced state after the crisis is referred

Resiliency

Benztropine 2 mg PO BID

For client receiving the antipsychotic medication clozapine (clozapine), what would be most important for the nurse to monitor?

Complete blood count

When the nurse checks the lithium level of a client on the unit, it is 2,0 mEq/L. What should the interpretation/action by the nurse be?

This level is high; the client should be assessed for manifestations of toxicity.

If a single dose of a drug is given and the drug has a half-life of 4 hours, what percentage of the drug will remain after 16 hours?

6.25%

When discussing pharmacokinetics, a patient experiencing gastrointestinal problems may have a problem with which process?

Absorption

“This classification is usually effective and generally causes fewer side effects."

When considering pharmacokinetics, what is the primary safety concern for a client prescribed lithium?

Increased risk for self-harm medication

The multidisciplinary team discusses the potential side effects of what medication prescribed to treat a patient's negative symptoms of schizophrenia?

Quetiapine

What aspect of traditional antipsychotic medication therapy is most responsible for a patient's medication nonadherence and resulting rehospitalization?

The occurrence of EPSEs.

Which breakfast selections demonstrate that a patient understands the nurse's dietary instructions while taking monoamine oxidase inhibitor (MAOI) antidepressants?

Oatmeal with almonds and milk

Altering serotonin levels

The nurse in the outpatient ECT clinic reviews the client's history for which of the following that might increase the client's risk during ECT?

Recent myocardial infarction

Mr. Erik Ramsey, scheduled for ECT treatment, does a correct preparation if he does which of the following?

Refraining from food and fluids for at least 8 hours before treatment

Which intervention would be the priority during the ECT Procedure?

Protecting client from falls

In the post-ECT recovery period, which finding would alert the nurse a possible problem?

Vital sign alteration

Which of the following is most likely to initiate a grief response in an individual? 1. Death of the pet dog 2. Being told by her doctor that she has begun menopause 3. Failing an exam

Death of the pet dog, Being told by her doctor that she has begun menopause, Failing an exam

Bargaining

A patient who continues to be tearful and has difficulty verbalizing feelings of sadness regarding a parent who died 11 years ago is experiencing which type of grief?

Chronic grief

Four teenagers are killed in an automobile accident. Three days later, which behavior indicates that one of the teenagers' parents is coping effectively with their loss?

Marks the site of the accident with flowers

A child dies after being struck by a car. The physician tells the parents, "Your child's injuries were so severe that there was nothing we could do." What is the initial intervention?

Stay with the parents until a support person arrives.

"How do you compare your activities and health now to 6 months ago?

A client says to the nurse, "Life doesn't have any oy How anymore. Things I once did for pleasure aren't fun." How would the nurse document this complaint:

Anhedonia

The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client with severe depression. The most reliable evaluation of outcomes will be based on

weekly weights.

Kindling may alter neuronal cell structure and function.

Which individual has the highest risk for major depression?

60-year-old man

"My body treats lithium just like salt."

Margaret, a 68-year-old widow, Is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. The patient who will require further teaching while on lithium would make what statement?

“I am really enjoying my aerobics dance class."

The patient refuses lithium for acute mania but is agreeable to another medication. The nurse will expect the prescriber to respond with what intervention?

Substituting the lithium with an anticonvulsant medication.

Which assessment question will the nurse ask to help identify the cause of a patient's decreased lithium levels?

"How much salt do you consume dally?"

What is the nurse's best response when asked by a patient who will begin lithium therapy, "When can I expect to see improvement in my symptoms?"

"We generally see symptom improvement in 7 to 10 days after beginning treatment."

Serotonin

In their initial interview, Nurse Crispin proposes that a suicidal cilent enter into a no-suicide contract. Such a contract would contain a provision that the client promises

not to attempt suicide in the next 24 hours.

Constant 24-hour, one-to-one observation at arm's length

The morning after he was admitted, a suicidal client wishes to use the cordless electric razor the staff took from his suitcase the night before. Nurse Crispin should:

allow him to use the razor under staff supervision.

A suicidal individual calls a suicide hot line managed by Nurse Crispin. This represents the level of intervention classified as

Secondary

An individual calls the hospital during the night shift in crisis and is considering suicide. The nurse will begin the interaction by saying which assessment question?

"Who is there with you right now?"

Which behavior demonstrates the most lethal plan by an individual who has recently expressed suicidal ideations?

Hoarding a large number of barbiturates

Which statement is most concerning regarding a depressed client's state of mind?

"Shooting myself with dad's gun will end it all quickly."

assessing the client's understanding of the risk depression presents for suicide.

ask the client if he is experiencing suicidal ideations with a plan to hurt himself.

"It's time to shower. I will help you."

The nurse expects to assess which of the following in a client with diagnosis of schizophrenia, paranoid type?

Auditory hallucinations, persecutory delusions

The nurse identifies the nursing diagnosis of Disturbed Thought Processes related to exhibiting delusions of reference for a client with schizophrenia. Which outcome would be most appropriate?

Client will talk about concrete events in the environment without talking about delusions.

Which nursing response would be most appropriate when a client about hearing voices?

"I do not hear the voices that you say you hear."

During a community meeting, a client with schizophrenia begins to shout and gesture in an angry manner. Which nursing intervention would be the priority?

Maintaining safety of client and others

-You are assigned in the community ward to take care of patients with schizophrenia. The nurse documents that a client is demonstrating a negative symptom of schizophrenia when observing the client:

having difficulty focusing on any task for more than a few minutes

Which statement regarding behaviors of psychotic clients made by a float nurse requires follow-up by the mental health unit's nurse manager?

“It must be so frightening to be psychotic since no one else can understand what you are feeling."

The nurse demonstrates an understanding of the most common co-morbid condition observed in a schizophrenic individual when asking:

"Would you describe yourself as being depressed?"

Which statement made by a nurse interviewing a client who reports the fear that people are trying to poison him requires follow-up by the nurse's unit manager?

“Tell me more about how someone keeps trying to poison your food”

The nurse is confident that an individual prescribed antipsychotic medication has been experiencing medication efficacy and showing insight when he:

is able to effectively assess the reality of his thinking processes

auditory hallucinations.

Affective flattening

*I understand that the voices are very real to you, but I do not hear them."

The nurse understands that which of the following represents the primary gain experienced by a client when giving in to a compulsion?

Decrease in anxiety

arrange for the client to have blood drawn for a white blood cell count.

Accepting client rituals

Impaired Social Interaction related to self-perceived feelings of rejection by peers

The technique of exposing a client to a fear-producing sensation in a gradual manner is called:

Systematic desensitization

Not allowing the client to wash hands after touching a "dirty" object

Antidepressants were prescribed by the physician for David. Of the following medications taken by the patient, the nurse knows that which of the following is a tricyclic antidepressant?

Clomipramine

Preoccupation with fear of serious disease

Impaired Physical Mobility related to leg pain secondary to conversion disorder

A client with somatization disorder is assessed for which of the following symptoms?

Physical symptoms for which no medical explanation exists

A client with body dysmorphic disorder is assessed for complaints of which of the following?

Preoccupation with defect

Which intervention would be most effective for a client with a somatoform disorder if the client continues to verbalize physical symptoms related to unmet dependency needs?

Limit-setting

Set limits on the amount of time the client may engage in the ritualistic behavior.

A potential problem that should be investigated for David if his obsessions and compulsions get out of hand is

sleep disturbance.

Which statement indicates that the patient with an anxlety disorder has developed a healthy coping strategy for dealing with sleep difficulties?

"The student nurse taught me relaxation techniques that I will continue to use at home."

During her initial interview, Diana says to the nurse, "I can't figure out why God would let this happen to me." From this statement, the nurse assesses which of the following in Diana?

Spiritual distress

determine use of chemical substances for anxiety relief

stay with Diana and reassure him of his safety.

Among the following therapeutic interventions, the nurse knows that this therapy can benefit most patients with PTSD

Group therapy

Diana is experiencing a panic attack. The nurse can be Most therapeutic by

telling the client to take slow, deep breaths.

Lorraine has been diagnosed with Somatization Disorder. Which of the following symptom profiles would you expect when assessing Lorraine?

Multiple somatic symptoms in several body systems

100

Which statement about somatoform and dissociative disorders is true?

Clients lack awareness of the relations among symptoms, anxiety, and conflicts.