Disorders
The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?
1. Use of confabulation
2. Improvement in sleeping
3. Absence of sundown syndrome
4. Presence of personal hygienic care
1.
The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning.
The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect?
1. When told that a beloved pet has died, the client responds, "OK."
2. The client giggled while describing being physically abused as a child.
3. The client's facial expressions are unchanged during the entire admission process.
4. When staff members attempt to engage the client in conversation, the client only mumbles.
2. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.
During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia?
1. Refusing to eat and excessive exercising
2. Eating only vegetables and fruits and fasting
3. Hoarding of food and difficulty controlling food intake
4. Eating a lot of food in a short period of time and misuse of laxatives
4. Eating binges and purging are the characteristic that would be seen in bulimia. Eating only certain types of foods may reflect a preference but does not indicate bulimia. Bulimic persons usually do not refuse to eat; rather, they binge and purge. Hoarding of food may indicate another problem.
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?
1. A crisis state indicates that the client has a mental illness.
2. A crisis state indicates that the client has an emotional illness.
3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis.
4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.
4.
Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.
A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement?
3. Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?
1. Incessant talking and sexual innuendoes
2. Grandiose delusions and poor concentration
3. Outlandish behaviors and inappropriate dress
4. Nonstop physical activity and poor nutritional intake
4. Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan?
1. Suggesting a reduction of medication
2. Allowing increased "in-room" activities
3. Increasing the level of suicide precautions
4. Allowing the client off-unit privileges as needed
3. A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.
The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?
1. Engaging in immoral acts
2. Always reinforcing self-approval
3. Observing rigid rules and regulations
4. Having the need always to make the right decision
3. Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients to manage their anxiety.
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?
1. Avoidant
2. Borderline
3. Schizotypal
4. Obsessive-compulsive
1. Avoidant
The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.
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?
1. "Have you talked to your family about this?"
2. "Everyone feels this way when they are depressed."
3. "You will feel better once your medication begins to work."
4. "You sound very upset. Are you thinking of hurting yourself?"
4.
Assess for SI and HI! These are considered life-threats
Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings.
The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder?
1. Depression
2. Schizophrenia
3. Somatization disorder
4. Obsessive-compulsive disorder
3.
Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.
The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors?
1. Signs of depression
2. Reactions to a devastating event
3. Evidence that the client is a high suicide risk
4. Indicative of the need for hospital admission
2.
During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate an expected reaction. Options 1, 3, and 4 are incorrect interpretations.
The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care?
1. Disrupted appearance because of weight
2. Inability to feed self because of weakness
3. Pain because of an inflamed gastric mucosa
4. Nutritional imbalance because of lack of intake
4. The priority client problem for the client with anorexia nervosa is lack of intake and nutritional imbalance since it is the basis of the condition. Although the problems identified in the other options may be considerations in the plan of care for the client with anorexia nervosa, nutritional imbalance is the priority.
The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?
1. Provide authority, action, and participation.
2. Display an attitude of detachment, confrontation, and efficiency.
3. Demonstrate confidence in the client's ability to deal with stressors.
4. Provide hope and reassurance that the problems will resolve themselves.
1. A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) "takes over" for the client (authority) who is not in control and devises a plan (action) to secure and maintain the client's safety. When this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies.
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?
1. "You need to try to be realistic. The rape did not just occur."
2. "It will take some time to get over these feelings about your rape."
3. "Tell me more about the incident that causes you to feel like the rape just occurred."
4. "What do you think that you can do to alleviate some of your fears about being raped again?"
3.
The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem solving totally on the client.
A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.
1. "I'm afraid of spiders."
2. "I keep reliving the robbery."
3. "I see his face everywhere I go."
4. "I don't want anything to eat now."
5. "I might have died over a few dollars in my pocket."
6. "I have to wash my hands over and over again many times."
2, 3, 5
Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with post-traumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions.
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.
1. Initiate confinement measures.
2. Acknowledge the client's behavior.
3. Assist the client to an area that is quiet.
4. Maintain a safe distance from the client.
5. Allow the client to take control of the situation
2, 3, 4
During the escalation period, 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. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.
The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply.
1. Assist the client in selecting foods from the food menu.
2. Offer high-calorie fluids throughout the day and evening.
3. Allow the client to eat alone in the room if the client requests to do so.
4. Offer small high-calorie, high-protein snacks during the day and evening.
5. Select the foods for the client to be sure that the client eats a balanced diet.
1, 2, 4
In caring for a client with depression whose nutritional intake is poor, the nurse should remain with the client during the meal. The nurse also should assist the client in selecting foods from the menu because the client is more likely to eat the foods that he or she likes. Offering small high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition.
Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression?
1. Restrict the client smoking for 12 hours.
2. Enforce nothing by mouth (NPO) status for 16 hours.
3. Limit the client's participation in unit activities for 24 hours.
4. Assure that an electrocardiogram is performed within 24 hours.
4. Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate. The remaining options are incorrect.
What statement should the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety?
1. "Try not to worry so much."
2. "I can see that you are becoming upset."
3. "Everything is going to be all right; just relax."
4. "Why are you having trouble controlling your anxiety?"
2. The correct option is the only one that addresses the client's feelings and concerns. Avoid options that provide false reassurance and place the client's feelings on hold. Avoid options that ask "why"; this nontherapeutic communication technique will increase the client's anxiety.
Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply.
1. Dementia
2. Panic disorder
3. Multiple personality disorder
4. Post-traumatic stress disorder
5. Obsessive-compulsive disorder
2, 4, 5
Multiple personality disorder is considered to be a dissociative disorder rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Dementia may or may not be associated with anxiety.
The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply.
1. Ask permission before touching the client.
2. Provide a warm, social approach to the client.
3. Eliminate all unnecessary physical contact with the client.
4. Defuse any anger or verbal attacks with a nondefensive stance.
5. Use simple and clear language when communicating with the client.
1, 3, 4, 5
When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client unless necessary and with the client's permission. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.
The nurse finds a client recently admitted with a diagnosis of anorexia nervosa engaged in a strenuous exercise routine. Which action should be the priority?
1. Interrupt the client, and offer to take her for a walk.
2. Allow the client to complete her exercise program.
3. Ignore the behavior, and return when the client is finished.
4. Tell the client that she is not allowed to exercise rigorously.
1.
When working with a client diagnosed with anorexia nervosa, the nurse must limit the amount of rigorous exercise that the client performs while providing for appropriate types and amounts of exercise. Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake, which causes further deterioration of their physical state. The correct option stops the harmful strenuous exercise and provides an unharmful form of exercise. The remaining options are inappropriate priority actions.
A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study?
1. Platelet count
2. Cholesterol level
3. Blood urea nitrogen
4. White blood cell count
4.
Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.
The nurse is planning to instruct a mental health client and the family about the importance of medication compliance. The nurse should plan for which interventions that are associated with increased compliance? Select all that apply.
1. Including the family in the medication planning process
2. Arranging medication administration to occur once per day
3. Working with the psychiatrist to find the right medication at the right dose
4. Providing the client with the injectable, long-acting form of the medication if available
5. Working with the psychiatrist to find the medication that provides the least side effects for the client
1, 3, 4, 5
Including the family in the medication planning process; providing clients with the injectable, long-acting form of the medication; and finding the right medication at the right dose that provides the fewest side effects for the client are measures that will promote compliance. Not all medications can be given on a once-per-day dosing regimen because of their short half-life.