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a. delusions.
b. hallucinations.
c. loose associations.
d. neologisms.
a. Restrict visits with the family until the client begins to eat.
b. Provide privacy during meals.
c. Set up a strict eating plan for the client.
d. Encourage the client to exercise, which will reduce her anxiety.
5. The nurse is caring for a client who she believes has been abusing
opiates. Assessment findings in a client abusing opiates, such as
morphine, include:
a. turning on the lights and opening the windows so that the client
doesn't feel crowded.
b. leaving the client alone.
c. staying with the client and speaking in short sentences.
d. turning on stereo music.
7. The nurse is teaching a new group of mental health aides. The nurse
should teach the aides that setting limits is most important for:
a. a depressed client.
b. a manic client.
c. a suicidal client.
d. an anxious client.
10. The nurse is caring for a client with manic depression. The care
plan for a client in a manic state would include:
a. Withdrawal
b. Logical thinking
c. Repression
d. Denial
a. impending coma.
b. manipulating behavior.
c. suppression.
d. perceptual disorders.
a. Aggressive behavior
b. Paranoid thoughts
c. Emotional affect
d. Independence needs
16. The nurse is caring for a client in an acute manic state. What's the
most effective nursing action for this client?
17. The nurse is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to:
a. avoid shopping for large amounts of food.
b. control eating impulses.
c. identify anxiety-causing situations.
d. eat only three meals per day.
18. The nurse is caring for a 40-year-old client. Which behavior by the
client indicates adult cognitive development?
19. A client with bipolar disorder is being treated with lithium for the
first time. The nurse should observe the client for which common
adverse effect of lithium?
a. Sexual dysfunction
b. Constipation
c. Polyuria
d. Seizures
21. During a shift report, the nurse learns that she'll be providing care
for a client who is vulnerable to panic attack. Treatment for panic
attacks includes behavioral therapy, supportive psychotherapy, and
medication such as:
a. barbiturates.
b. antianxiety drugs.
c. depressants.
d. amphetamines.
RATIONALE: The nurse should remain with the client until the attack
subsides. If the client is left alone, he may become more anxious.
Giving false reassurance is inappropriate in this situation. The client
should be allowed to move around and pace to help expend energy.
The client may be so overwhelmed that he can't follow lengthy
explanations or instructions, so the nurse should use short phrases and
slowly give one direction at a time.
24. A client with paranoid type schizophrenia becomes angry and tells
the nurse to leave him alone. The nurse should:
a. tell him that she'll leave for now but will return soon.
b. ask him if it's okay if she sits quietly with him.
c. ask him why he wants to be left alone.
d. tell him that she won't let anything happen to him.
RATIONALE: If the client tells the nurse to leave, the nurse should leave
but let the client know that she'll return so that he doesn't feel
abandoned. Not heeding the client's request can agitate him further.
Also, challenging the client isn't therapeutic and may increase his
anger. False reassurance isn't warranted in this situation
a. psychotic symptoms.
b. parkinsonism.
c. akathisia.
d. dystonia.
RATIONALE: These symptoms describe dystonia, which commonly
occurs after a few days of treatment with haloperidol. The symptoms
may be confused with psychotic symptoms and misdiagnosed.
Parkinsonism results in muscle rigidity, shuffling gait, stooped posture,
flat-faced affect, tremors, and drooling. Signs and symptoms of
akathisia are restlessness, pacing, and inability to sit still
a. benztropine (Cogentin).
b. diphenhydramine (Benadryl).
c. propranolol (Inderal).
d. haloperidol (Haldol).
a. Calcium
b. Sodium
c. Chloride
d. Potassium
a. "I think you're wrong. France is a friendly country and an ally of the
United States. Their government wouldn't try to kill you."
b. "I find it hard to believe that a foreign government or anyone else is
trying to hurt you. You must feel frightened by this."
c. "You're wrong. Nobody is trying to kill you."
d. "A foreign government is trying to kill you? Please tell me more
about it."
32. A 26-year-old male reports losing his sight in both eyes. He's
diagnosed as having a conversion disorder and is admitted to the
psychiatric unit. Which nursing intervention would be most appropriate
for this client?
34. A client is being admitted to the substance abuse unit for alcohol
detoxification. As part of the intake interview, the nurse asks him when
he had his last alcoholic drink. He says that he had his last drink 6
hours before admission. Based on this response, the nurse should
expect early withdrawal symptoms to:
a. not occur at all because the time period for their occurrence has
passed.
b. begin anytime within the next 1 to 2 days.
c. begin within 2 to 7 days.
d. begin after 7 days.
35. Which of the following factors would have the most influence on
the outcome of a crisis situation?
a. Age
b. Previous coping skills
c. Self-esteem
d. Perception of the problem
36. The nurse is caring for an elderly client in a long-term care facility.
The client has a history of attempted suicide. The nurse observes the
client giving away personal belongings and has heard the client
express feelings of hopelessness to other residents. Which intervention
should the nurse perform first?
38. A high school student is referred to the school nurse for suspected
substance abuse. Following the nurse's assessment and interventions,
what would be the most desirable outcome?
39. The nurse is using drawing, puppetry, and other forms of play
therapy while treating a terminally ill, school-age child. The purpose of
these techniques is to help the child:
RATIONALE: Children may not have the verbal and cognitive skills to
express what they feel and may benefit from alternative modes of
expression. It's important for the child to find a way to express
internalized feelings. The child must also know that he isn't to blame
for this situation. In the process of doing play therapy, the child can
also have fun, but that isn't the main goal of therapy
40. The nurse is working with a client who abuses alcohol. Which of the
following facts should the nurse communicate to the client?
41. One staff member in a psychiatric unit says to the nurse, "Why are
we carrying out suicide precautions for someone who is dying? It's
pointless and a waste of time." The nurse should:
42. The client with dual diagnoses of major depression and alcohol
abuse states, "I only drink when I can't sleep." An initial outcome for
this client is that the client will:
45. A client walks into the mental health clinic and states to the nurse,
"I guess I can't make it without my wife. I can't even sleep without
her." Which of the following responses by the nurse would be most
therapeutic?
46. During the conversation with the nurse, a victim of physical abuse
says, "Let me try to explain why I stay with my husband." Which of the
following reasons would the client be LEAST likely to mention?
47. During a home visit, the client tells the nurse she's not taking
prescribed doses of haloperidol (Haldol) because she's tired of
bothering with it and doesn't need it. The nurse's best action is to:
48. The client has been taking the monoamine oxidase inhibitor (MAOI)
phenelzine (Nardil), 10 mg bid. The physician orders a selective
serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given
every morning. The nurse:
a. Summon another nurse to help ensure that the client takes her
medicine.
b. Tell the client that she can take the medication either orally or by
injection.
c. Withhold the medication until it is determined why the client is
refusing to take it.
d. Tell the client that she needs to take her "vitamin" to stay healthy.