Foundations
A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication?
A. "You have everything to live for"
B. "Why do you see yourself as a failure?"
C. "Feeling like this is all part of being depressed"
D. "You've been feeling like a failure for awhile?"
What is D
Restating
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult?
A. psychosis
B. repression
C. conversion disorder
D. dissociative disorder
What is C
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
A. Ask the client why he started taking illegal drugs
B. Ask the client about the amount of drug use and its effect
C. Ask the client how long he thought that he could take drugs without someone finding out
D. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home
elicit information in a nonjudgmental way
The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question?
A. "With whom do you live"
B. "Who is available to help you"
C. "What lead you to seek help now"
D. "What do you usually do to feel better"
What is C
asking what caused the crisis will help the nurse to plan appropriate interventions
A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory results to monitor for adverse effects from this medication?
A. Platelet count
B. Blood glucose level
C. Liver function studies
D. White blood cell count
What is D
agranulocytosis
interrupt treatment if wbc is less than 3,000
The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication?
A. "I see"
B. "Really?"
C. "You're having difficulty sleeping?"
D. "Sometimes I have trouble sleeping too"
What is C
Restatement
A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?
A. Place the client in seclusion for 30 minutes
B. Tell the client that the behavior is inappropriate
C. Escort the client to their room, with the assistance of other staff
D. Tell the client that their telephone privileges are revoked for 24 hours
What is C
Seclusion is premature at this time
Denying privileges may only escalate the behavior
The nurse determines that the wife of an alcoholic client is benefiting from attending Al-Anon group meetings if the nurse hears the wife make which statement?
A. "I no longer feel that I deserve the beatings my husband inflicts on me"
B. "My attendance at the meetings has helped me to see that I provoke my husband's violence"
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 they are common among alcoholics"
What is A
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response?
A. "Have you talked to your family about this?"
B. "Everyone feels this way when they are depressed"
C. "You will feel better once you medication begins to work"
D. "You sound very upset. Are you thinking of hurting yourself?"
What is D
safety is primary concern
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5. The nurse plans care based on which representation of this level?
A. toxic
B. normal
C. slightly elevated
D. excessively below normal
What is A
toxicity begins at 1.5 - 2
maintenance level is between 0.6 and 1.2
What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?
A. Ask the client to leave the group for this session only
B. Refer the client to another group that includes other manic clients
C. Tell the client to stop monopolizing in a firm but compassionate manner
D. Thank the client for the input, but inform the client that others now need a chance to contribute
What is D
specific and provides direction to the client
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which is the best intervention the nurse should include?
A. Increase socialization of the client with peers
B. Avoid using a whisper voice in front of the client
C. Begin to educate the client about social supports in the community
D. Have the client sign a release of information to appropriate parties for assessment purposes
What is B
plan of care must address the problem, which is paranoid personality disorder
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?
A. Hypotension, ataxia, hunger
B. Stupor, lethargy, muscular rigidity
C. Hypotension, coarse hand tremors, lethargy
D. Hypertension, changes in level of consciousness, hallucinations
What is D
The emergency department is caring for an adult client who is victim of family violence. Which priority instruction should be included in the discharge instructions?
A. information regarding shelters
B. instructions regarding calling the police
C. instructions regarding self-defense classes
D. explaining the importance of leaving the violent situation
What is A
the nurse is assisting the client after the abuse occurred. information regarding safe places and plans for removing the self from the abuser is priority
The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication?
A. 2 months
B. 2-3 weeks
C. during the first week
D. during the sixth week of administration
What is B
The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected?
A. "Autonomy is the fundamental right of each and every client"
B. "A client's rights are guaranteed by both state and federal laws"
C. "Being respectful and concerned will ensure that I'm attentive to my client's rights
D. "Regardless of the client's condition, all nurses have the duty to value client's rights
What is C
shows understanding or respect for the concept
A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern?
A. "I don't believe this is true"
B. "The guards are not out to kill you"
C. "Do you feel afraid that people are trying to hurt you"
D. "What makes you think the guards were sent to hurt you"
What is C
the nurse should empathize with the client
encouraging discussion regarding the delusion is inappropriate
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse?
A. "Why don't you tell your spouse about this"
B. "What do you find difficult about this situation"
C. "This is not the best time to make that decision"
D. "I agree with you. You should get out of this situation"
What is B
encourages the spouse to problem solve
A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?
A. requesting that a peer remain with the client at all times
B. removing the client's clothing and placing the client in a hospital gown
C. assigning to the client a staff member who will remain with the client at all times
D. admitting the client to a seclusion room where all potentially dangerous articles are removed
What is C
constant observation by a staff member is the best action
The nurse is administering risperidone to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client?
A. get adequate sunlight
B. continue driving as usual
C. avoid foods rich in potassium
D. get up slowly when changing positions
What is D
orthostatic hypotension
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply
A. Restating
B. Listening
C. Asking the client, "why"
D. Maintaining neutral responses
E. Providing acknowledgment and feedback
F. Giving advice and approval or disapproval
What are A, B, D, E
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? select all that apply
A. communicate expected behaviors to the client
B. ensure that the client knows that they are not in charge of the nursing unit
C. assist the client in identifying ways of setting limits on personal behaviors
D. follow through about the consequences of behavior in a nonpunitive manner
E. enforce rules by informing the client that he/she will not be allowed to attend therapy groups
F. have the client state the consequences for behaving in ways that are viewed as unacceptable
What are A, C, D, F
Which interventions are most appropriate for caring for a client in alcohol withdrawal? select all that apply
A. monitor vital signs
B. provide a safe environment
C. address hallucinations therapeutically
D. provide stimulation in the environment
E. provide reality orientation as appropriate
F. maintain NPO status
What are A, B, C, E
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? select all that apply
A. initiate confinement measures
B. acknowledge the client's behavior
C. assist the client to an area that is quiet
D. maintain a safe distance from the client
E. allow the client to take control of the situation
What are B, C, D
the client's behavior is moving toward loss of control. nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate
A hospitalized client is started on phenelzine for the treatment of depression. the nurse should instruct the client that which foods are acceptable to consume while taking this medication? select all that apply
A. figs
B. yogurt
C. crackers
D. aged cheese
E. tossed salad
F. oatmeal raisin cookies
What are C and E
Avoid tyramine with MAOIs