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Suzie approached the nurse asking for advice on how to deal with her alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:
Abstinence
A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?
Paranoid Thoughts
Rationale: Due to excessive social anxiety which can lead to paranoid thoughts.
A 39-year-old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. The nurses realizes that the basis of O.C. disorder is often:
Feelings of guilt or inadequacy.
Rationale:
Ritualistic behavior in this situation is aimed at controlling guilt and inadequacies by maintaining set absolute behaviors.
To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?
Respect the clients need for personal space.
Rationale:
Moving into the client's space increase the feelings of a threat which increases anxiety.
The nurse is aware that extremely depressed clients seem to do best in settings where they have:
Routine activities.
Rationale:
Because depression is emotional and physical, simple daily routines are best and produce the least amount of stress and anxiety.
A nurse is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, the nurse should…
Watch the patient.
Rationale:
Patients who are suicidal should be monitored continuously.
The nurse is caring for a 41-year-old female client. Which behavior by the client indicates adult cognitive development?
Generates new levels of awareness.
Rationale: adults aged 31-45 generate new levels of awareness.
A patient is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
Limiting the behavior.
Rationale:
By setting limits to the patient's manipulative behaviors helps to control the dysfunctional behavior. This requires a consistent staff approach.
The nurse recognizes that the focus of environmental (MILIEU) therapy is to:
To manipulate the environment to bring about positive behaviors.
Rationale:
Milieu therapy aims to have everything in the client's surrounding area aimed to help them.
To further assess a client’s suicidal potential. The nurse should be especially alert to the client expression of:
Helplessness and hopelessness
Rationale:
Expressions of these feelings can indicate that the client is unable to continue the struggle of life.
A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
Stay with the client and speak in short sentences.
Rationale: Speak in short sentences, decrease stimuli, remain calm, and medicate if needed.
A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?
Respiratory distress.
Rationale: ABC's
A patient with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
Discuss the meaning of the statement with the patient.
Rationale: Any suicidal statement should be assessed in order to determine the terms of suicide.
A 60-year-old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend.
The nurse recognizes that the client is using the defense mechanism known as?
Denial
Rationale:
Denial is a defense that blocks problems by unconsciously refusing to admit they exist.
A nursing care plan for a male client with bipolar I disorder should include:
Provide a structured environment.
Rationale:
Structure provides security and decreases agitation and anxiety.
A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
That they are highly important and famous.
Rationale:
Delusion of grandeur lends to believing that one is famous and important.
The nurse can minimize agitation in a disturbed client by?
Limiting unnecessary interaction.
Rationale:
This will decrease stimulation and agitation.
A client with antisocial personality disorder belches loudly. A staff member asks the client, "Do you know why people find you repulsive?" this statement most likely would elicit which of the following client reaction?
Defensiveness
Rationale:
Due to the belittling nature of the question, the natural reaction is to attack and preserve the self-image.
A client is pacing the floor and appears extremely anxious. The nurse approaches in an attempt to alleviate their anxiety. The most therapeutic question by the nurse would be?
Would you like me to talk with you?
Rationale:
The presence of the nurse may help the client feel in control and supported.
When planning care for a female client using ritualistic behavior, the nurse must recognize that the ritual:
Helps the client to control their anxiety.
Rationale:
Rituals used by clients with OCD help to control their anxiety level by maintaining a set pattern of action.
A 20-year-old client was diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective individual coping?
Inability to make decisions and answer questions without advice from others.
Rationale:
Persons with dependent personality disorder exhibit indecisiveness, submissiveness, and clinging behavior.
A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer's type and depression. The symptom that is unrelated to depression would be?
Shallow of labile effect.
Rationale:
With depression there is little or no emotional involvement and therefore, little alteration in affect.
Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
Supportive confrontation.
Rationale:
This helps the nurse to point out to the client the discrepancies between what they state and what actually exists to increase self-responsibility.
The nurse is aware that the symptoms that distinguish post-traumatic stress disorder from other anxiety disorder would be:
Re-experiencing the stress or trauma in dreams or flashbacks.
Rationale:
Dreams or flashbacks that distinguishes PTSD from other anxiety disorders.
A nurse is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
Abuse occurs more often in low-income households.
Rationale:
Abuse is relative to the characteristics of the abuser such as low self-esteem, immaturity, dependence, insecurity, and jealousy.