Mental Health

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?

Projection

Projection is a defense mechanism in which the client refuses to acknowledge unacceptable personal characteristics and transfers feelings thoughts, or traits onto another personInstead of dealing with his own failures, the client is describing the shortcomings of the course and teacher

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutritionWhich of the following actions should the nurse take to improve the client's nutritional status?

Sit with the client during meals and snacks

A change in appetite is a major symptom of depressionBeing present during meals and snacks to support and encourage the client is an appropriate nursing intervention that might help the client at this time

A nurse is caring for a postpartum client who tells the nurse that she does not want any more children. The client asks which birth control methoc the nurse would recommend. Which of the following responses should the nurse make?

Let’s talk about the available options and go from there

This response illustrates the therapeutic communication technique of formulating a plan of actionIt demonstrates the nurse's willingness provide information so that the client can make an informed choice that will meet her needs at this time

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorderWhich of the following statements should the nurse include in the teaching?

You will need to stop this medication if you experience diarrhea

Diarrhea can lead to dehydration and potentially elevated lithium levels and toxicityDiarrhea, vomitingand lethargy can also indicate lithium toxicity. The nurse should inform the client to stop taking the medication if the any indications of lithium toxicity occur.

A nurse in a mental health facility is preparing to interview a client who is has schizophrenia. Which of the following actions should the nurse take?

Sit beside the client rather than facing him

The nurse should sit beside the client the nurse should sit beside90 degree angle from him so that direct eye contact is unnecessarySitting facing the client directly can cause him to feel uncomfortable and can make the interview more intense.

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?

Proving for adequate hydration and rest

Providing for the client's physical needs should be the nurse's priority until the client completes the detoxification phase of treatmentRest is important for two reasons: alcohol use disrupts normal sleep patterns, and alcohol withdrawal or detoxification is often associated with increased restlessness and agitationRestoring and maintaining and electrolyte balance is another important goal during detoxification to prevent and electrolyte imbalances

A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia . The client's parents are tearful and express feelings of Which of the following statements should the nurse make ?

You said that you feel guilty about your daughter's diagnosis. Lets talk about what is causing you to feel this way

This statement is an example of clarification and promotes further discussion which is a therapeutic communication technique

A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorderWhich of the following client goals is the highest priority?

The client's withdrawal from alcohol will be managed without complications

The greatest risk to the client is injury and adverse effects of withdrawal therefore, this goal is the highest priority

A nurse in a mental health is discussing guided imagery with a newly licensed nurseWhich of the following clients should the nurse suggest offering the therapy to?

Post-traumatic Stress Disorder

Guided imagery is a recommended treatment to relieve the anxiety associated with posttraumatic stress disorderis a complementary alternative therapy also used to treat sleep disorders, anxiety, and pain

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?

The client runs 4 miles outdoors every afternoon

Strenuous exercise in outdoor heat, which can lead to dehydration puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to toxicity , but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and that have been lost through profuse sweating This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea and taking diuretics

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

I check any room enter because the enemy is still after me and could be anywhere

This client is making a paranoid statement something more typical a client who has This statement is not of a client who has PTSD

A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV) He states, don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something i don't haveThe nurse identifies that the client is experiencing which of the following types of crisis?

Situational

A diagnosis of HIV is a situational crisis which is one that is unexpected but is part of regular life such as a serious illness or loss

A nurse in an emergency department is assessing a client who has traumatic injuries following an assaultThe client sits quietly and calmly in the examination room and states, fine.The nurse should recognize the client's behavior as which of the following reactions?

Denial

Denial is a defensive coping mechanism that protects the from increasing anxiety levelsThe client consciously intolerable thought and ideas. It is a common response of victims of violent crimes

nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

Preparing for artificial ventilation

Delirium, severe vital sign changes, and apnea may be present in the client who has serotonin syndrome. Preparing for artificial ventilation the priority intervention when taking the airway, breathing, circulation approach to client care

A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hairWhich of the following responses by the nurse is therapeutic?

I see you did some grooming today

This response is open-ended, and this response is therapeutic because it offers the client recognition of positive behavior and encourages further discussion

A nurse is caring for a client who has a depressive disorder. The client statesjust can't feel any happiness or joy in lifeWhich of the following terms should the nurse use when documenting this finding?

Anhedonia

Anhedonia refers to the client's inability to experience pleasure or joy.

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted He states that he is finding it more and more difficult to care for his wife Which of the following interventions is the nurse's priority?

Ask the partner to talk about his difficulties in caring for the client

The first action the nurse should take using the nursing process priority framework is to assess the partner's difficulties in caring for his wife

A nurse is planning care for a client who has obsessive-compulsive disorder (OCD)Which of the following actions should the nurse plan to take

investigate what situations precipitate anxiety

Obsessions are recurrentpersistent, and impulsive thoughts that increase anxiety. Compulsions are repetitive behaviors performed in an attempt to decrease anxiety. The client is more likely to be able to interrupt obsessions she is assisted to identity the types of situations or events which precipitate anxiety.

During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?

I don’t care about work anymore since I was not given a promotion

Regression is reverting to an earlier, more primitive and child -like pattern of behavior If a promotion is lost maladaptive regression is seen through poor work performance , missing appointments , and being late

A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to rule out medical conditions which could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions?

Hypothyroidism

The expected findings of hypothyroidism, including changes in weight, sleep disturbances decreased energy , and changes in thought processes mimic those of a major depressive episode.

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, want to go home; my husband is waiting for me to cook dinnerWhich of the following responses by the nurse is appropriate?

Tell me what you like to cook for dinner.

Alzheimer's disease is a progressive cognitive disorder. Dementia due to Alzheimer's disease means that the client is experiencing stages of the with moderately severe to severe cognitive decline. By asking the client to talk about what she likes to cook for dinner the nurse demonstrating validation therapy by asking the client to talk about the areas that concern herThe nurse could continue the conversation by discussing how much the client misses her home and partner. Validation therapy helps clients who have cognitive disorders discuss their feelings about past events and people.

A nurse is caring for a client who has major depressive disorder (MDD)Which of the following findings should the nurse expect

Significant change in weight

A significant change in weight, either loss or gain, is an expected finding of MDD

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs Which of the following responses should the nurse make?

I will help you get ready and then you can rest

This statement shows caring by the nurse and provides for a balance between activity and rest which is an appropriate intervention for the who has depression

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eatingWhich of the following statements should the nurse make?

Come with me. Here is a milkshake to drink

When working with a client who is experiencing mania, the nurse should provide short, firm, and concise directions, which can provide a feeling of safety for the client and can distract the client from inappropriate activities, such as vigorous exerciseAn appropriate activity for the client is to accompany the nurse to a quiet place away from the clients who are trying to eatClient nutrition is important, but the client often needs foods that can be held in the hand and eaten easily while walking. The client is unlikely to be able to sit in one place for long enough to complete a meal when experiencing mania

A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and divorce. Which of the following is the priority nursing action?

Preventing self-directed violence

Prevention of injury addresses the greatest safety risk to the client and is therefore the priority action

A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT)Which of the following responses by the staff nurse indicates understanding of the teaching?

Informed consent should be obtained prior to ECT

ECT is a treatment that requires informed consent from the client or authorized person

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurseYester noon the sun moon went over the rover to see the lawnmower.Which of the following manifestations is the client exhibiting ?

Associative looseness

The client who is manifesting associative looseness has ideas that do not connect to each other and are expressed in garbled and illogical speech This is a typical disturbance for the client who has schizophrenia

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Talk to the chent and identify the specific limits that are required of the client's behavior

Discussing the problem behaviors with the client and informing her of which behaviors cannot be done on the unit is therapeutic communication

A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawnWhich of the following actions should the nurse take to promote client communication?

Be direct and honest when speaking with the

The nurse promotes communication to the client who is quiet and withdrawn by using direct and honest communication. This manner which conveys support fosters trust between the client and to promote communication for the withdrawn

A nurse is caring for a client who is receiving treatment for alcohol withdrawalWhich of the following findings is the highest priority?

Illusions

illusion may occur during severe alcohol withdrawal and prevent the greatest safety risk to the client, and are therefore the priority finding

A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client

A room containing personal belongings

A room that contains several of the client's personal belongings assists in maintaining personal identity and provides a therapeutic environment

A nurse reviews the laboratory report for a client who is receiving lithium three times daily POThe client's current blood level is 1.8 /L. The nurse identifies that this lab value indicates which of the following?

The lithium level is at the toxic level

A blood lithium level greater than 1.5 indicates toxicityThe should the for manifestation coarse hand tremors, confusion, drowsinessand should withhold the lithium and notify the providerA therapeutic blood level of to levels for maintenance should be between and 1.3

A nurse is caring for a client who has schizophreniaWhich of the following statements by the client indicates concrete thinking?

I am aware that each problem has only one solution

This statement is an example of concrete thinking which refers to the client's inability to think abstractly

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?

Hand tremors

Course tremors of the hands is an expected finding of alcohol withdrawal

A nurse is caring for a client who reports acute, moderate anxietyWhich of the following is the priority nursing action?

Remain with the client

The greatest risk to this client is self-injury from impulsive behavior therefore the nurse should stay with the to reduce anxiety and the client feel safe.

A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect ?

Viral infection

The nurse should expect to find the client with a decreased immune response which leads to viral bacterial infections in response to chronic stress

A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take

Determine the client's need for assistance with grooming

The nurse should promote problem-solving by helping the client identify situations which can or cannot be controlled This can help the client deal with unresolved issues

A nurse in an emergency department is assessing a who has been taking haloperidol for 3 monthsThe client has a temperature of (103.4) blood pressure of 150/110 mm and muscle rigidityWhich of the following complications should the nurse suspect

Neuroleptic malignant syndrome

CORRECT Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of antipsychotic medications that requires emergency medical interventionManifestations NMS are sudden and include changes in level of consciousness, , and

A nurse is preparing to administer selegiline for a client who is admitted with major depressionWhich of the following actions should the nurse take ?

Apply to dry skin on the client's upper thigh

CORRECT Selegiline, a monoamine oxidase inhibitor (MAOI) is administered only by the transdermal route to treat depressionIt can be administered orally treat Parkinson's disease and other disorders

A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several yearsWhich of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)

Twisting tongue movement

A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at risk for a vitaminB6 deficiency

A who has chronic use disorder

CORRECT The nurse should recognize that alcohol consumption destroys and increases elimination of vitamin B6 from the body therefore this client is at risk for vitamin B6 deficiency

A nurse is providing care for a client who seems anxious following a recent tragedy. Which of the following statements by the client reflects an adaptive use of sublimation?

I will work out in the gym every time get mad about what happened.


CORRECT represents sublimation which dealing with unacceptable feelings or impulses by substituting acceptable forms of an adaptive defense mechanism and the use of this can be encouraged by the nurse to assist the client in decreasing anxiety

A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily livingWhich of the following statements should the nurse make to the client?

I will assist you in getting out of bed and getting dressed

CORRECT Severely depressed persons have problems with selfcare and are easily overwhelmedA nursing approach that focuses on meeting the client's and basic needs directly best. The presence of the nurse conveys that the is worthy of the nurse's attention and help the adjust to the hospitalization

nurse is caring for a who has schizophrenia and is experiencing a hallucinationWhich of the following actions should the nurse take?

Ask the client the direct questions about the hallucination

CORRECT Asking the client direct questions about the hallucination provides important data to identify the client's risk level and current mental status

A nurse in an acute care mental health facility is assessing a client who has bipolar disorderWhich of the following findings indicates the at risk for ?

client's behavior has become impulsive in the past few weeks

CORRECT The presence of impulsive behavior is a primary risk factor for suicide and clients who have mania can act in a manner which is hostile, aggressive and impulsive

A nurse is planning care for a client who has dementia, Which of the following interventions should the nurse include in the plan of care

the client's choices for daily activities

CORRECT Limiting the client's choices is appropriate for a client who has dementia as this intervention decreases the client's level of anxiety

A nurse is caring for a group of clients in an acute mental health facilityWhich of the following clients has the legal right to refuse treatment?

An older adult client who was voluntarily admitted

CORRECT Competent admitted voluntarily are legally able to refuse treatment at any time during the course of their care

A nurse is conducting a group therapy meeting and is sharing a humorous storyWhen the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling"You are all making fun of meWhich of the following behaviors is this client displaying?

Ideas of reference

Ideas of reference occur when a client believes that conversations of others always concern him and that others are ridiculing him

A nurse is caring for a group of clients on a mental health unitWhich of the following actions should the nurse implement to establish therapeutic relationships with the clients?

Demonstrate genuineness when communicating

The nurse should demonstrate genuineness during the nurse-client relationship to establish trustAn honest, caring attitude shows concern and facilitates an emotional connection with the client

A nurse is performing an admission assessment for a client who has schizophrenia . Which of the following findings should the nurse identify as a negative symptom?

Affective flattening

My Affective flattening is an example of a negative symptom of schizophrenia

A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit Which of the following actions should the nurse take

Set limits on the client's behavior and be consistent in approach

CORRECT When caring for a who is experiencing a manic episode, the nurse should communicate acceptable behavior to the client and should be consistent with consequences when the behavior plan is not followed

A nurse is providing medication teaching for a client who has a new prescription for phenelzine. Which of the following statements should the nurse include in the teaching?

You should change positions slowly while taking this medication

CORRECT Clients should change positions slowly while taking an MADI due to the risk of orthostatic hypotension Lightheadedness and fainting are common when taking phenelzine

A nurse asks a client who is suicidal to make a safety contract, but the client declinesWhich of the following actions should the nurse identify as the priority?

Assign a member to stay with the at times

CORRECT The greatest to this is selfduring time, therefore, the nurse should identify the priority action is to assign a member to stay with the client at all times The staff member can monitor of the client's behaviors and actions and prevent the from herself

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is boredWhich of the following activities is appropriate for the nurse to suggest to this client ?

Walking with the nurse in the courtyard

Clients who have bipolar disorder are prone to hyperactivity The nurse should provide activities that provide a way for the client to release physical energywhile avoiding situations that might provoke the client In addition, walking with the nurse provides an opportunity for therapeutic communication

A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest

Major depressive disorder

a client who has major depressive disorder experiences periodic major depressive episodes and is at greatest risk for suicide during these times

A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to several classmates and a school teacherWhich of the following responses by the nurse is appropriate to give?

I cannot promise thatI must share this information with other members of the team who are responsible for planning your care

CORRECT The nurse should report issues that are potentially life-threatening to the treatment teamAlthough trust is the hallmark of the nurse- client relationshipconfidentiality does not extend to these situations

A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?

You should keep your provider's and therapist's number with you"

CORRECT The client should have a written plan, including important numbers, available at all times in case relapse occurs

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

Check the client's mouth after the client takes medication

CORRECT My This action is appropriate for clients who have paranoid schizophrenia as it helps assure that the client is swallowing medication

A nurse is planning care for a client who is being treated for acute PHENCYCLIDINE intoxication. Which of the following should the nurse include in the plan of care

Monitor for hypertension

A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unitWhich of the following actions should the nurse take first ?

Set behavioral limits for the client

The nurse should first set behavioral limits for the client to stop harming others

A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation?

It was good. The Queen of England visited me there."

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan?

"I know which of my hallucinations trigger a relapse."

A nurse is collecting a health history on a client who has a diagnosis of wernicke-korsakoff syndrome. Which of the following is an expected finding?

personal history of alcohol use disorder

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through tasks one step at a time. !!!

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating The flakalas are hereThe flakalas are hereThe nurse correctly recognizes the client's use of the word flakala as an example of which of the following alterations in speech?

Neologism

A nurse in an acute care mental health facility is admitting a client who reports feeling depressed , sad, moody, and overly anxiousWhich of the following is the nurse's assessment priority ?

Suicide risk

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out". Which of the following would be the most appropriate response for the nurse to make?

You feel that you don't belong here?

A nurse is providing teaching for a patient who has binge-eating disorder and is morbidly obese. The patient has been prescribed orlistat. Which of the following statements indicates to the nurse that the patient understands the teaching?

C. "I will stop taking orlistat and call my doctor if my urine gets darker in color."

Rationale: Orlistat can cause severe liver damage; therefore, the client should be taught manifestations of liver damage, including dark-colored urine, light-colored stools, jaundice, anorexia, vomiting, and fatigue.

A nurse in an acute care mental health facility is preparing to administer morning meds for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the fallowing actions should the nurse take?

Administer the morning dose of lithium.
therapeutic range 0.8 - 1.3 mEq/L

A nurse in a mental health facility is caring for a client in the busy facility dining room during lunchtime when suddenly the client becomes angry and throws a chair. Which of the following interventions should the nurse perform first?

Attempt to talk the client down

A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy . The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?

Tell me more about your concerns about taking chemotherapy."

A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?

Agoraphobia

A nurse is caring for a client who is receiving treatment for alcohol detoxification. What medication should the nurse expect to administer during this phase of the client's care?

Diazepam.

Anti-anxiety agents, such chlordiazepoxide and diazepam, are long-acting CNS depressants that are used to minimize the manifestations of alcohol withdrawal

The parents of a 4-year-old child who has a serious chronic illness tell the nurse that they have taken their son's name off the list for little league baseball next season. Which of the following is an appropriate nursing response to the parents?

It must be frustrating for you to have to cancel an activity your son enjoyed."

A nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility the
following morning. The client asks the nurse why he has to go to "that place." Which of the following responses should
the nurse make?

"Did your doctor or anyone else talk to you about going to the nursing home?"

nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?

Carbamazepine

A nurse in the emergency dept. is planning care for a client who is admitted for an overdose of PCP. Which of the following actions should the nurse plan to take?

Administer ammonium chloride.

Ammonium chloride acidifies the urine and promotes excretion of PCP. In addition, the nurse should monitor the client's respiratory status and be prepared to assist with intubation and mechanical ventilation.

A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit?

The client follows directions.

- The nurse needs to carefully assess the client to determine when she is ready for reintegration. Indications that the client is ready include the ability to following directions and control behaviors. The nurse should provide a gradual reintegration to allow the client to adjust to the increased stimulation and provide continual observation during the process.

A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?

A client who is taking clozapine (Clozaril), and has flu symptoms, fever, and aching joints.

The nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

"It's okay to feel scared. Let's talk about what you are afraid of."

A nurse is caring for a client who has a mental illnessWhich of the following actions by the nurse demonstrates the ethical concept of autonomy?

Supporting the client's wish to refuse prescribed medications

A nurse in a community clinic facility notices a change in a client's behaviorWhich of the following manifestations is the priority for the nurse to report?

Onset of command hallucinations

A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?

"You should try to see your partner's point of view before your own."

A nurse in a long term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Provide a consistent daily routine.

A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors?

Has alcohol use affected your performance at work?

A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?

Echolalia

A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statements should the nurse make?

You may hold your baby as long as you want."

Holding the newborn is essential because it helps the client confront the reality of the loss and facilitates progression through the grief process.

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

Command hallucination

A home health nurse is speaking to a group of acute care nurses about domestic violenceWhich of the following statements by one of the care nurses indicates a need for clarification?

I have heard that abusers think of themselves as important and have high self esteem

A nurse is conducting group therapy session for several clientsThe group laughing one of the when a who is schizophrenic jumps up and runs out of the room yellingYou are all making fun of The nurse should identify this behavior as which of the following characteristics schizophrenia

Ideas of reference

a nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. which of the ff responses should the nurse make?

"let's try to find ways to incorporate your partner's favorite food into her diet plan"

A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission Which of the following actions should the nurse take ?

Ask the client to describe the situation

is admitting a client to an alcohol abuse programThe client states, here because of my was part of my job to go to parties and drink with clientsThe client's statement is an example of which of the following defense mechanisms

Rationalization

A nurse is caring for a client who has anorexia nervosa and over-exercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.

school nurse is talking with a 13-year-old female at her annual health screening visitWhich of the following comments made by the adolescent should be the nurse's priority to address?

None of the kids at this school like me, and I don’t like them either

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lbs.) in the past three months. The client weighs 40 kg (88 lbs.) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Identify the clients nutritional status

A nurse in a psychiatric unit is caring for several clientsWhich of the following clients should the nurse recommend for group therapy?

A client who has been taking amitriptyline for 3 months for depression

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?

Give positive feedback when client is assertive with staff or clients

During the evening shift, a client in an acute mental health facility commits suicide. Which of the following is the priority intervention for staff following this incident?

Identify cues in the client's behavior that might have warned staff that he was contemplating suicide.

A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention?

Take the client outside for a walk.

Clients who are experiencing mania are at risk for physical exhaustion; therefore, the nurse should redirect the client to a different activity that will decrease stimulation and slow the client's physical activity expenditure.