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During an assessment interview, a depressed 15-year-old girl .1 states that she "can't sleep at night. The nurse begins to explore factors that contribute to this situation by asking if the girl is sexually active. The girl changes the subject. What should the nurse suspect based on the client's response to the assessment ?question a. Sexual abuse .b. Narcolepsy c. Spiritual distress d. Pain disorder
RATIONALE: Victims of sexual abuse commonly refuse to talk about the abuse or change the subject because they have been threatened by their abuser. Although there may be other explanations for the adolescent's inability to sleep at night, such as noise, anxiety, spiritual distress, pain, or other disturbance, adolescents are typically willing to discuss these factors as contributors to their inability to sleep. An adolescent with narcolepsy would experience brief periods of deep sleep followed by periods of feeling refresh and wouldn't complain of being .unable to sleep at night A client, age 20, is being treated for depression. During a .2 conversation with a nurse, the client states that her father raped her when she was 7 years old. She says she has nightmares about the experience and sometimes relives it. She also reveals :that she fears older men. Thw nurse suspects that the client has a. posttraumatic stress disorder (PTSD), delayed onset. c. Anxiety disorder b. multiple personality disorder d. Schizophrenia
RATIONALE: The client's memory of a traumatic childhood incident and her current signs and symptoms( nightmares, flashbacks, and related fears) suggest that she has PTSD with delayed onset. The client doesn't occasionally lose track of her movements and actions, flashbacks, these aren't psychotic episodes, as in .schizophrenia A nurse knows that a physician has orders the liquid form of .3 the drug chlorpromazine (Thorazine) rather than the tablet form :because the liquid a. has a more predictable onset of action. .produces fewer drug interactions b. produces fewer anticholinergic effects. .duration of action c. d. has a longer
RATIONALE: A liquid phenothiazine preparation will produce effects in 2-4 hours. The onset with tablets is .unpredictable During periods of extreme stress a client may experience .4 elevated blood pressure, dilated pupils, and increased respiration. These unconscious responses originate in which part ?of the brain a. Limbic system b. Hypothalamus c. Reticular activating system d. Somatic nervous system
RATIONALE: The hypothalamus regulates the unconscious responses associated with fight-or-flight response of the autonomic nervous system. The limbic system, located in the middle of the brain, is responsible for emotional expression, learning, and memory. The reticular activating system, which projects from the brainstem to the thalamus, controls sleeping and wakefulness. The somatic nervous system provides .voluntary control over skeletal muscles A client is in the manic phase of bipolar disorder. To help the .5 :client maintain adequate nutrition, the nurse should plan to a. provide large, attractive meals c. provide a stimulating mealtime environment
b. offer finger foods and sandwiches let the client choose his favourite foods
RATIONALE: Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's high energy level. During the manic phase, the client can't still for large meals. Providing a stimulating mealtime environment is incorrect because a quiet mealtime environment is more beneficial than a stimulating one. Letting the client choose his favourite food s is inappropriate because this client has a short .attention span and has trouble making choices Teaching for women of childbearing years who are receiving .5 ?antipsychotic medications includes which statement .a. This medication may result in heightened libido b. Incidence of dysmenorrhea may increase while taking this .drug c. Continue previous contraceptive use even if you're .experiencing amenorrhea .d. Amenorrhea is irreversible RATIONALE: Women may experience amenorrhea, which is reversible, while taking antipsychotics because amenorrhea doesn't indicate cessation of ovulation the client who experiences amenorrhea can still become pregnant. She should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of an antipsychotics, and the depressant generally decrease .libido A client with a diagnosis of paranoid schizophrenia is admitted .6 to the inpatient unit of the mental health center. He's shouting that the government of France is trying to assassinate him. ?Which response is most appropriate a. "I think you're wrong. France is a friendly country. The French "French government wouldn't try to kill you b. " I don't see evidence 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 RATIONALE: Responses should focus on reality while acknowledging the client's feelings. It isn't therapeutic for the nurse to argue with client or deny his belief. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusion may aggravate the client's psychosis. Asking the client if a foreign government is trying to kill him may increase his .anxiety level and can reinforce his delusion A client with a history of heroin addiction is admitted to the .7 hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's father states that he's going to have his son declared legally incompetent. ?Which response by the nurse is most therapeutic a. " Your son is ill and can't make decisions about himself ".and his safety right now, but this situation is temporary b. "You don't have the right to declare your son incompetent. He ".has rights, too c. " If you become your son's guardian, you'll be responsible for ".his finances and for paying for his treatment d. " If you become your son's guardian, you'll be responsible for ".his finances and paying for his treatment RATIONALE: The client is temporarily unable to make decisions about his health care and safety. After receiving emergency care and treatment, he'll probably be able to safely manage his daily affairs. The nurse's reference to the client's constitutional rights isn't a .therapeutic response :Positive symptoms of schizophrenia include .8 a. hallucinations, delusions, and disorganized .thinking .b. Somatic delusions, echolalia, and a flat affect .c. waxy flexibility, alogia, and apathy .d. flat affect, avolition, and anhedonia
The client's complaints don't involve his ability to perform in his roles. avolition. Ineffective role performance . the treatment will help you RATIONALE: In this statement.RATIONALE: The positive symptoms of schizophreniahallucinations. A nursing :diagnosis for this client might include . Don't feel bad. apathy. the nurse acknowledges the client's traumatic experience and pain and encourages the client to talk. " :The nurse's most supportive response would be a. Situational low self-esteem RATIONALE: All symptoms define a disturbance in selfesteem. There isn't enough information to determine delayed growth and development. " It's important for you to talk with your physician about an ". decrease libido.d. sensitivity to criticism. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data .conscious.soon enough c. Delayed growth and development . and feeling self.issue such as this ". She feels depressed and asks the nurse. " I'm not sure what is wrong. delusion. a client reports that she . " It sounds like you have some unresolved pain about the trauma.obtained from this client During the admission interview. and disorganize thinking. " Do you think I will ever get better? I don't know what is wrong with me. alogia.b. A nurse who tells the client .d.a. and anhedonia refer to the negative symptoms. Posttrauma syndrome .c.are distortions of normal functioning. Take time while you're here to talk and allow ". He also has aches and pains.10 frequently has nightmare and memories of a rape that occurred 3 years earlier.yourself to heal b. A flat affect. but the medication will help you ". Negative symptoms characterize the .9 complains of fatigue.diminution or loss of normal function A client seeking help at a community mental health center .
or talents. " Just ignore situations you can't change d. jealous delusion RATIONALE: Somatic delusion focus on bodily functions or systems and commonly include delusion s about foul odor emissions. internal parasites. " Maybe we could schedule a time to discuss this ". Telling the client not to feel bad could make the client feel guilty for being upset about the . Delusion of grandeur.12 rotted from the worms chewing on them. " Try to take some deep breaths whenever you feel anxious ". Jealous delusion are delusions that one's spouse . wealth. Referring the client to the physician indicates that the nurse isn't capable of helping the client deal with therapeutic issues. " My intestines are . and misshapen parts.13 valid psychiatric and nursing theories. insect infestations. " I'm having a hard time taking care of mentally ill people.a.b. A nurse's interpersonal . " Maybe you should attend some stress-reduction courses ". " This statement :indicates a a. Delusion of persecution are morbid beliefs that one is being mistreated and harassed by unified enemies.problem at a more appropriate time A client with schizophrenia tells the nurse.that she doesn't know what is wrong but that medication will help ignores the client's need for reassurance. c. somatic delusion D. a .11 newly graduated nurse approaches the charge nurse and states. Delusion of persecution b. What can I do to handle this stress?" The charge nurse's best response :is ".further RATIONALE: Suggesting to set a time for a more detailed discussion acknowledges that the charge nurse is concerned about what the new graduate has told her and provides an opportunity to explore and address the . Delusion of grandeur are gross exaggerations of one's importance.or lover is unfaithful Nursing care for a client with schizophrenia must be based on .c. power.trauma During an extremely busy shift on the psychiatric unit.
a.the situation warrants RATIONALE: A flexible care plan is needed for any client who behaves suspicious.choosing with clothing to wear .roles .14 personality disorder. which the client with dependent personality . Spending long periods of unscheduled time with the client b. with boundaries and specifically defined . warm and nonthreatening . a nurse should ?provide which instruction to the client .b.c. clearly identified. or regressed manner .15 antipsychotic agent haloperidol (Haldol) . Avoiding discussion of the client's feelings of helpless RATIONALE: Helping the client identify preferences promotes development of independent decision-making skills. 10mg by mouth twice per day.b. Take the medication 1 hour before a meal . During a discharge teaching session. Decrease the dosage if signs of illness decrease . such as . Apply a sunscreen before exposure to the sun d. Which intervention should the nurse include ?in this client's care plan to promote independence .or who has a though disorder A nurse is assigned to care for a client with dependent . Increase the dosage up to 50 mg twice per day if signs of .illness don't decrease .a. Scheduling competitive activities so the client can test his . flexible enough for the nurse to adjust the care plan as . Helping the client identify preferences.skills c.c.communication with the client and specific nursing interventions :must be a.disorder lacks A client is about to be discharged with a prescription for the .d. centered on clearly defined limits and expression of empathy d. withdrawn.
What ?instruction should the nurse include a. a nurse explains how family members can participate effectively in the client's ongoing care.16 complaining of headaches. the nurse should use the refusal as an opportunity to learn more about feelings.do just fine d. the nurse instruct the client to apply a sunscreen before exposure to the sun. you'll ". reevaluate and change the ".to describe his feelings is the most therapeutic response When doing discharge planning for a hospitalized client with .the dosage unless a physician orders the change The client with a posttraumatic stress disorder has been .medication . "Persuade him to go to an emergency department and request ". "I can tell you're really afraid. The nurse also should teach the client to take haloperidol with meals-not 1 hour beforeand should instruct the client not to decrease or increase .approach you use b.17 impulse control disorder. Can you tell me about "?your fear RATIONALE: The client is experiencing intense fear.physically wrong ". "Recognize initial anger symptoms as soon as possible and ". "I'm not going into that ?tunnel!" Which response by the nurse is most therapeutic a.have him take medication c. Acknowledging the client's fear and asking him . "If you take several deep breaths and close your eyes. " This is the only way the physician can tell there's anything ". " Consistently reward positive behaviour and reinforce ". " After every explosive outburst.consequences of negative behaviour d. A physician orders magnetic resonance imaging (MRI) of the brain in order to rule out organic disorder. "Many people feel the same way about having an MRI c. The client later tells a nurse. Rather than reasoning with the client.b.RATIONALE: Because haloperidol can cause photosensitivity and precipitate severe sunburn.
outbursts.the client's best approach A female client is admitted to the emergency department . and the nurse should question the use of these drugs in a client with cardiac disease. The response is commonly seen in victims of sexual abuse.18 after being sexually assaulted.c. Discontinue the medication . analysis.b. Which action should the nurse take . Administer the medication as ordered . Question the physician about the order d. the client attempts to avoid expressing emotions associated with the stressful .situations by using logic. It involves consciously disowning intolerable thoughts and impulses. Displacement RATIONALE: Denial is a protective and adaptive reaction to increase anxiety. the inconsistency of this approach isn't in .a. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behaviour as a protective defense mechanism. Denial c. Regression d.RATIONALE: Consistency in rewarding positive behaviour and reinforcing consequences of negative behaviour is essential if the family is going to help the client learn to control angry feelings. Changing the approach after every angry outbursts isn't appropriate.19 has suffered an acute myocardial infarction (MI) within the ?previous 6 months. A nurse can't discontinue a medication without the physician's order. Administering the medication would be an act of negligence.physician RATIONALE: Cardiovascular toxicity is a problem with antidepressants. It's the nurse . Intellectualization b. In intellectualization. ?What defense mechanism is the client excibiting a. and reasoning A physician orders a tricyclic antidepressant for a client who . Inform the client that he should discuss his MI with the . and actions.
She . Schizophreniform disorder RATIONALE: In delusion disorder of the erotomanic type.b. calling.jealous type . and stalking. " As long as we're understanding and supportive.with the physician Which response demonstrates that the parents of a child with .psychiatric diagnosis for this client .21 believes he loves her and eventually will marry her and she has been sending him cards and gifts. " His grandfather is an alcoholic. These parents demonstrate on an understanding of they'll need to take an active role in monitoring their child's . What is the most probable .20 newly diagnosed schizophrenia understand their child's ?diagnosis a. he'll ". The object of the undesired attention may be a complete stranger or someone the . Delusion disorder.d.medication therapy A client stalks a man she met briefly 3 years earlier.adolescence d. Being around him caused our ".eventually be fine c. and usually is of higher status .a. a judge orders her to undergo a 10-day psychiatric evaluation.if he doesn't b.responsibility. When she violates a restraining order he has obtained. the client has an erotic delusion of being loved by another person and tries to contact the object of the delusion through such behaviours as sending gifts. "We'll watch him swallow his daily pills and call the physician ". not client's.son to have this problem RATIONALE: Treatment for schizophrenia involves taking medication on a consistent basis. to discuss question of care . Induced psychotic disorder .c. Delusion disordererotomanic type . " The illness is a result of drug abuse during early ".client knows.
Support is available to help family members meet their . neck. The nurse should also teach clients' family members that medication can't prevent relapses and that environmental stimuli may . Tardive dyskinesia RATIONALE: Dystonia.a.nutritional status . Three days later.b.stimulating environment .d. akathesia.24 :should plan to focus this client's care on a. offering nourishing finger foods to help maintain the client's .M. the . back. and tardive dyskinesia.precipitate symptoms A client with chronic schizophrenia receives 20 mg of . to abnormal muscle movements. face. This client is exhibiting which extrapyramidal reaction a. to restlessness or inability to sit still. the client has muscle contractions that contort ?his neck.22 ?nurse should provide which information . manifests as muscle spasm in tongue. providing emotional support and individual counselling . Relapse can be prevented if the client takes his medication b. and sometimes the legs.particularly around the mouth A client is in the first stage of alzheimer's disease.When teaching the family of a client with schizophrenia.own needs c. Improvement should occur if the client is provided with a . Dystonia b. The nurse . a common extrapyramidal reaction to fluphenazine decanoate . . Akathisia d. Akinesia refers to decreased or absent movement. injection. Akinesia c.23 fluphenazine decanoate ( prolixin decanoate) by I. the nurse inform them of support services that can help them cope with such problems. Stressful family situations can precipitate a relapse RATIONALE: Because family members of a client with schizophrenia face difficult situations and great stress.
d. Before administering the drug. to solve the client's problems for him . psychological resolution of the immediate crisis .c. Guanethidine. Concomitant use of which drug is likely to ?increase the risk of extrapyramidal effects (a. Droperidol (Inapsine (c. suggesting new activities for the client and family to enjoy . Lithium carbonate and alcohol .c. to establish a basis for long-term therapy . low self-esteem. fatigue. His physician orders the phenothiazine chlorpromazine ( Thorazine). and difficulty . The client must learn to resolve his own issues.27 depression. nursing care typically focuses on providing emotional support and .25 schizophrenia.b.therapy isn't the goal of crisis intervention A client visits a physician's office to seek treatment for .26 . a nurse reviews the client's medication history. Lithium carbonate (Lithonate d.individual counselling A client is admitted to the psychiatric unit with acute onset of . to provide a basis for admission to an acute care facility RATIONALE: The goal of crisis intervention is to resolve the immediate problem. insomnia.together RATIONALE: Clients first stage of alzheimer's disease are aware that something is happening to them and may become overwhelmed and frightened. feelings of hopelessness.don't increase the risk of extrapyramidal effects :The goal of crisis intervention is . Although some clients do enter long-term . 100 mg by mouth four times per day. poor concentration. Guanethidine (Ismelin (b.a. monitoring the client to prevent minor illness from turning into . alcohol RATIONALE: When administerd with any phenothiazine. Therefore. poor appetite.major problems d. droperidol may increase the risk of extrapyramidal effects.
listen to a personal stereo through headphones and .parasympathetic stimulation A client with schizophrenia tells a nurse he hears the voices of . the nurse should expect to see which cardiovascular effect produced by the sympathetic nervous ?system a.normal mood that last a few days to few weeks A client admitted to the unit is visibly anxious. atypical affective disorder. sit in a quiet.a. appetite disturbance. and hopelessness.d. difficulty making decisions. low selfesteem. Based on this report.making decisions. low energy or fatigue. major d. cyclothymic disorder. poor concentration.disorder c. Decrease blood pressure c. . When . peripheral vasoconstriction. Syncope is a response to a . the nurse suspects a. Decrease pulse rate RATIONALE: Sympathetic cardiovascular responses to stress include increased heart rate.c. and cardiac output.depression b. accompanied by at least two of the following symptoms: sleep disturbance. the nurse :should recommend that he . These symptoms may be relatively continuous or separated by intervening episodes of . cardiac contractility. Syncope rate b. dark room and concentrate on the voices b. The client states that these symptoms began :at least 2 years earlier. by listening to music through headphones) may . To help the client ignore the voices.29 his dead parents. engage in strenuous exercise RATIONALE: Increasing the amount of auditory ( for example. call a friend and discuss the voices and hi feeling about them . dysthymic RATIONALE: Dysthymic disorder is characterized by feelings of depression lasting 2 years. Increase heart d.28 assessing this client. increased blood pressure. .sing along with the music .
Then you go home RATIONALE: Scheduling the client as the first appointment and arranging to talk him after having his blood drawn is a practical intervention that provides the client with the opportunity to express his feelings .fine b. and giving away treasured possessions suggest that this adolescent is contemplating suicide. the adolescent is brought to the community mental health :agency for evaluation.31 with family members. This adolescent is at risk for a. " The procedure takes only a few minutes.drawn ".30 have blood drawn. I'm sure you'll do just ". This adolescent's signs and symptoms don't suggest fear of school and .afterward An adolescent becomes increasingly withdrawn.help the client focus on external sounds and ignore internal sounds from auditory hallucinations.they typify depression. After giving away a stereo and some favourite clothes. suicide b. "I'll arrange for you to be the first client and we'll talk ". school phobia d. Concentrating on the voices would make it harder for the .about it afterward c. stating.32 ?is the strongest indicator that child abuse may be a problem . " You've come a long way in therapy. social withdrawal.client ignore the hallucinations A clinic client with agoraphobia must go to a laboratory to . The client is terrified." What is the nurse's most ?therapeutic response a. Anorexia nervosa would cause weigh loss and other related symptoms. " It sounds like you've had bad experiences having your blood ". not schizophrenia When interviewing the parents of an injured child. " I know I can't handle being in the waiting room. is irritable . and has been getting lower grades in school. anorexia nervosa c. which sign .d. schizophrenia RATIONALE: Changes in academic performance and familial communications.
c. Have blood levels screened weekly for leukopenia d. The injury isn't consistent with the child's history or . It's imperative that a client using MAO inhibitors check . Don't take an MAO inhibitor with aspirin or nonsteroidal anti. ideas of reference d. The nurse suspects the client is experiencing a. A delusion is a false belief.33 :secret message. such as the television newscaster sending a message directly to her. The family is poor and the mother and father isn't married d. Avoid strenuous activity because of the drug's cardiac effects .age .34 ?about monoamine oxidase (MAO) inhibitors a.nurse should suspect child abuse A client can tells a nurse that the television is sending her a .(inflammatory drugs (NSAIDs RATIONALE: When combined with a number of drugs MAO inhibitors can cause life threatening hypertensive crisis.b.pharmacist . The parents offer consistent explanations for the injury .a. a hallucination RATIONALE: Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to an individual.objects. Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another. the emergency department . flight of ideas c. A hallucination is a sensory perception.b. The parents are argumentative and demanding with .personnel RATIONALE: When the child's injuries are inconsistent with the history given or if the injuries couldn't have occurred naturally or accidentally because of the child's age and developmental stage. Don't take any prescribed or over-the-counter medications without consulting a physician and .c. such as hearing voices and seeing . a delusion b. that only the client experiences Which statement should be included when teaching clients .
Violent people generally are jealous and . Which blood study should be performed before discharge as a baseline for ?identifying adverse effects of the medication .c.d. Because this is the client's first hospitalization.other medications A client with major depression sleeps 18 to 20 hours per day. . the nurse should determine that the :husband .35 shows no interest in activities he previously enjoyed and reports a 17-lb (7. Phenelzine isn't ordered initially because it may cause many adverse effects and necessitates dietary restrictions. To assess for the likelihood of further violence and abuse.36 because he slapped her repeatedly the night before.a. This couple is at risk for further violence. Fasting blood glucose. Electrolyte tests . The husband indicates that his childhood was marred by an abusive relationship with his father. trusts his wife and supports her independence . impulse control indicates a risk for more violence. Thiothixene and trifluoperazine are antipsychotic agents and therefore inappropriate wuth the client with .a. has moderate impulse control .possessive and feel insecure in their relationships A physician orders carbamazepine (Tegretol) for a client with . nortriptyline (Pamelor d. has learned violence as an acceptable behaviour . not moderate. the physician is most likely to :order (a. phenelzine ( Nardil) (b. feels secure in his relationship with his wife RATIONALE: Family violence is usually a learned behaviour.37 the diagnosis of intermittent explosive disorder.with his physician and pharmacist before taking any . trifluoperazine (Stelazine RATIONALE: Nortriptyline.b. Poor. is used in first-time drug therapy because it causes few anticholinergic and sedative adverse effects. a trycyclic antidepressant.7-kg) weight loss over the past month. thiothixene ( Narvane) c. c.uncomplicated depression A husband and wife seek emergency crisis intervention .
limit setting.7 meq/L.V. the nurse refuses to :return the client's personal effects.doesn't affect cholesterol A group therapy. I've done it before. I can quit whenever I want. violation of confidentiality RATIONALE: Confirming a voluntary client against his will may be considered false imprisonment. the nurse should have a CBC performed before discharge. This action is an example of . Electrolyte tests aren't normally performed because this drug doesn't alter electrolytes unless the client experiences overdose. Complete blood count (CBC).is denying drug .40 ( Eskalith) 300 mg t. Carbamazepine doesn't tent to alter fasting blood sugar. Rationalization RATIONALE: A client who states that he doesn't have a drug problem and can quit using drugs at any timedespite evidence to the contrary.confidentiality hasn't been violated A client with bipolar disorder is taking lithium carbonate . Limit setting is a technique used with clients who are manipulative to limit manipulative behaviour toward nurses and other clients. In assessing the client at his clinic visit. Cholesterol studies aren't needed because of this drug . heroin every day .d.b. so .studies d. . " I don't have a drug problem. Denial b. Compensation d.39 treatment is complete. The nurse hasn't given out any information about the client.b. Cholesterol RATIONALE: Because carbamazepine can cause immunosupression. a client who has used I. His lithium level is 2. Identification c. false imprisonment. slander D." Which defense ?mechanism is the client using a.i. c. The first assessment question the nurse :should ask before ordering another blood test is . the nurse finds no evidence of lithium toxicity. Slander is oral defamation of character.addiction A voluntary client in a facility decides to leave the unit before .38 for the past 14 years says.a. . To detain the client.
blood drawn too soon after his last dose One of the goals for a client with anorexia nervosa is for the . impending coma b.suicidal ideation c. perceptual disorders RATIONALE: Anxiety.a. and agitation are generally the first indications of active alcohol withdrawal.d. irritability. irritability d.medication problems b. The client drinks 4 L of fluid per day . The client's last . they can begin within a few hours of cessation of drinking. The client talks almost constantly with friends by telephone RATIONALE: The client is moving toward meeting the goal because recording and discussing feelings is a constructive way to manage stress.2 mEq/L.41 client to demonstrate increased individual coping by responding stress in constructive ways. Which finding indicates to ?the nurse that he is beginning active alcohol withdrawal a. The client keeps a journal and discusses it with the . Which action is the best indicator ?that the client is working toward meeting the goal .likely to use pacing to burn calories and lose weight A client is admitted for alcohol withdrawal. whether the client is embarrassed or afraid to report .d. whether the client understands why he's taking this . whether the client is experiencing depression and having .a.medication . This client's lithium level is extremely high. The client paces around the unit most of the day c. especially .nurse .6 to 1. the anorexic client is more . The nurse needs to determine when the client took a dose of lithium in relation to having his blood drawn because the test results may have been affected if the client had his . Although physical activity can reduce stress. manipulating behaviour c.42 drink was 2 hours before admission. when the client took his last dose of lithium RATIONALE: Normal lithium level range from 0.b. Perceptual disorders.
Clozapine is used to manage symptoms of schizophrenia . .c. " ?The nurse is using which therapeutic technique a. 2 mg orally twice per day . restating b. 200 mg orally twice per day RATIONALE: Alprazolam's antianxiety properties make it the most appropriate medication for this client. Clozapine ( Clorazil). A large group of reporters with cameras is camped out in the hospital parking lot. As a nurse walks to the employee parking after her shift. making observations c.frightening visual hallucinations. The nurse respond s.d. "You may want to talk about your employment situation in group today. 0.in client's who don't respond to other antipsychotic drugs A well-known client suffers a psychotic break and is admitted . Chlorpromazine is used to control the severe symptoms seen in clients with psychosis.day .of withdrawal A client reports losing his job. Chlorpromazine ( Thorazine). a reporter asks if she knows anything about the client's condition. Benztropine (Cogentin).25 mg orally three times per . She didn't restate the question ( restating technique) or ask further questions ( exploring technique).43 and feeling upset with his wife. What is the most ?appropriate response .observation A nurse refers a client with severe anxiety to a psychiatric for . not being able to sleep at night. Alprazolam (Xanax). are very common with alcohol withdrawal and usually occur on the second day .44 medication evaluation.b. Benztropine is an antiparkinsonian agent used to control the extrapyramidal effects of such antipsychotic agents as chlorpromazine hydrochloride and thioridazine hydrochloride. The physician is most likely to order ?which psychotropic drug regimen on a short-term basis a. and didn't make an . focusing RATIONALE: The nurse is using focusing by suggesting that the client discus a specific issue. 25 mg orally three times per day .45 to the psychiatric unit. exploring d.
" I can't answer your questions RATIONALE: Telling the reporter that she can't respond to the question is the most appropriate response by the nurse. Encouraging the client to express her feelings at meal times RATIONALE: Restricting access to food. Restricting the client's access to food except at .specified meal and snack times . Which nursing action is most ?appropriate for this client a.emotions c. She states that she is unworthy of eating and that her children will die if she eats. Paroxetine ( Paxil RATIONALE: Haloperidol is the drug of choice for treating Tourette syndrome. Haloperidol ( Haldol (d.c. guilty.eats b. .46 (a. in turn. except at specified times.47 to eat when stressed shows a lack of interest in eating at meal times.d. " Get away from me and don't take any pictures ". Telling the client that she may become sick and die unless she . decreases her association of these emotions with food. " All I can say is that the client is safe and stable ". including a client's admission to the hospital. Fluvoxamine ( Luvox (c. Fluvoxamine. or depressed.". prevents the client from eating when she feels anxiety. and paroxetine are antidepressants and aren't used to .d.confidentiality ?Which is the drug of choice for treating Tourette syndrome .b. Fluoxetine.Tourette syndrome A client with delusional thinking who is overweight and tends . " I didn't have an opportunity to assess this client ". All information. is protected by the client's right to .a. this. Paying special attention to the client's meal-related rituals and . Fluoxetine ( Prozac (b.
about death a lot b. I might take matters into my ".own hands ".home c.the restraints are applied . Checking that the restraints have been applied .restrained b. The clients she should . has a specific plan and has the means readily available. " I'm thinking of driving my car into a tree on the way ".behaviour A nurse works in a suicide crisis clinic.medication c. " If my life doesn't get better.d. or talks about wanting to die or attempting suicide is considered at a lower risk for suicide because this behaviour typically serves to alert others that the client is contempting suicide and wishes . " I gave my clothes away because I'm depressed and think ".correctly . Paying special attention to this client's meal-related rituals and emotions would reinforce her undesirable .Telling the client she may become sick or die may reinforce her behaviour.48 consider to represent the higher risk for suicide are those who :state a. Reviewing facility policy regarding how long the client may be . illness or death may be her goal. The nurse should document the client's response and status carefully after . thinks about death. A client who gives away possession.d.49 ?restraining a violent client a. Preparing an as-needed dose of the client's psychotropic . Asking if the client needs to use the bathroom or if is thirsty RATIONALE: A nurse must determine whether the restraints have been applied correctly to make sure that the adequate padding has been used. " I'm always thinking about dying RATIONALE: The client at higher risk for suicide is one who plans a violent death.to be helped Which nursing intervention is most important when .
52 ? antipsychotic medications include which statement .through the day so that he'll sleep at night c.eat a complete meal Teaching for women of childbearing years who are receiving . Incidence of dysmenorrhea may increase while taking this .neutral attitude.to finish all his food b.b. Which . This medication may result in heightened libido b.drug . High-calorie finger foods should be offered to supplement the client's diet if he can't remain seated long enough to . insisting that the client remain active through remain active .manipulative behaviour without setting limits d. The client doesn't harm himself or others d. offering high-calorie meals and strongly encouraging the client . and avoiding power struggles RATIONALE: The nurse should listen to the client's requests. therefore. express willingness to seriously consider each request. The client spends more time by himself . The nurse should encourage the client to take short daytime naps because he expends so much energy. having the client spend more time by himself wouldn't be a desirable outcome.51 :plan for a client in a manic state would a. Rather.c. demanding. allowing the client to exhibit hyperactive. . The care .a. a desirable outcome would specify that the client spend more time with other clients staff on . Listening attentively to the client's requests with a .needs RATIONALE: The client with schizophrenia is commonly socially isolated and withdrawn.a. The client demonstrates the ability to meet his own self-care . The client doesn't engage in delusional thinking .50 ?outcome requires revising the client's care plan .unit A client is caring for a client with bipolar disorder.A nurse is caring for a client with schizophrenia.
What is the best way ?for the nurse to address this situation a. Helping the client identify preferences.c.contraceptive use even when experiencing amenorrhea A nurse is assigned to care for a client with dependent .inappropriate manner c. Spending long periods of unscheduled time with the client b. She should be instructed to continue .d. Scheduling competitive activities so the client can test his skills c.set limits on the amount of time she spends with him A nurse is in the dining room and overhears a new nurse tell a . while taking antipsychotics because amenorrhea doesn't indicate cessation of ovulation the client who experiences amenorrhea can still become pregnant. Amenorrhea is irreversible RATIONALE: Women may experiencing amenorrhea.client .experiencing amenorrhea . Which intervention should the nurse include ?in this client's care plan to promote independence a. which is reversible. Continue previous contraceptive use even if you're . The client bursts into tears and runs out of the dining room.specific diagnosis b. Ask the new nurse why she made that statement to the . Ask the new nurse how much she knows about the client's . To demonstrate that she is available during set times in a structured relationship.53 personality disorder.54 client with body dysmorphic disorder that she's much too thin and must eat more before she can go home. Inform the new nurse that she handled the situation in an . the nurse should spend scheduled. Avoiding discussion of the client's feelings of helplessness RATIONALE: Helping the client identify preferences promotes development of independent decision-making skills which the client dependent personality disorder lacks. time with client and should . not unscheduled. such as choosing which clothing to wear d.
55 sulphate ( Parnate). and fresh fish Before the nurse administers the first dose of lithium .57 ?(the central nervous system (CNS . a client who reports eating aged cheese requires additional teaching.56 carbonate (Lithonate) to a client. Which statement accurately describes the metabolism ?and excretion of lithium .as poultry.unchanged by the kidneys Which effects do most antipsychotics medications exert on . Ask the new nurse to refrain from speaking with this client in . It's metabolized in the liver and excreted by the kidneys RATIONALE: Lithium isn't metabolized and is excreted .needs A client with major depression is taking tranylcypromine . The client may safely consume low-tyramine foods. the child should avoid consuming high-tyramine foods. she reviews information about the drug.a. this situation is an opportunity for the more experienced nurse to guide the new nurse and act as a mentor. Whole grain bread c. whole grain bread. because the interaction may cause lifethreatening hypertensive crisis. It's metabolized and excreted by the kidneys c. The nurse understands that additional teaching is needed when the ?client expresses he ate which food a. Aged cheese d. such . a monoamine oxidase ( MAO) inhibitor.b. Asking about the new nurse's rationale for her statement creates an opportunity for her to expand her critical thinking skills and improve her ability to relate to clients with unique . Free-range poultry b.the future RATIONALE: Because the client is safe. It's metabolize in the liver and excreted in the feces .kidneys . Fresh fish RATIONALE: When taking an MAO inhibitor. such as aged cheese. It isn't metabolized and is excreted unchanged by the .d. Therefore.d.
b.norepinephrine. norepinephrine. and norepinephrine d. and serotonin receptors b. a calming effect from which the client is easily aroused d. They sedate the CNS by stimulating serotonin at the synaptic . alert and responsive and has a good motor . They depress the CNS by stimulating the release of . serotonin.59 has been preoccupied and distant for several days and is having difficulty focusing on her clients' needs.58 the psychiatric unit.difficult to arouse RATIONALE: Shortly after phenothiazine administration. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day.a. more prolonged sedative effects. They stimulate the CNS by blocking postsynaptic dopamine.cleft c.coordination A nursing supervisor notices that a previously effective nurse . What should the ?supervisor say to the nurse a.c. serotonin. making the client more . . " I think you need to spend more time worrying about your "clients .acetylcholine RATIONALE: The exact mechanism of antipsychotic medication action is unknown. but the client is aroused. and they stimulate neurotransmitter action or . but these drugs appear to depress the CNS by blocking the transmission of three neurotransmitters: dopamine. a quieting and calming effect occurs.acetylcholine release A client with tentative diagnosis of psychosis is admitted to .transmission of dopamine.a. Phenothiazines differ from central nervous system ( CNS) depressants in their :sedative effects by producing . They depress the CNS by blocking the postsynaptic . deeper sleep than CNS depressants . Antipsychotics don't sedate the CNS by stimulating serotonin. greater sedation than CNS depressants .
before RATIONALE: Observing that the nurse seems asking if she'd like to talk is a supportive and encouraging approach that allows the nurse to identify and address the problem in a collaborative manner. Sit quietly next to her . tension and irritability b. slow pulse c. Enter the room quietly and move next to the client to assess .60 :assessing this client. not constipation is a common . Surrounded by broken glass.which the nurse may already be aware A client is admitted for an overdose of amphetamines. she sits staring blankly at the laceration.61 treatment clinic has moderate lacerations on both wrist. Call for staff back-up before entering the room and restraining . When . Would you "?like to talk "?c.What is the most important action for the nurse to ?take next to the client a. Amphetamines stimulate norepinephrine . constipation RATIONALE: Amphetamines are nervous system stimulant that are subject to abuse because of their ability to produce wakefulness and euphoria. An overdose increases tension and irritability.b. the nurse should expect to see a.the client . which increases the heart rate and blood flow. Diarrhea. parental.her injuries b.c. " I've noticed you seem to be preoccupied. Suggesting that the nurse should spend more time worrying about her client's in accusatory. hypotension d. " Do you feel your current assignment is too demanding d. " What is going on with you? You've always done so well ".adverse effect A client found sitting on the floor of the bathroom in the day . and states a problem of .
The client must be instructed to continue taking the drug as directed. . not bradycardia.62 buspirone (BuSpar).initiating therapy to check blood levels of the drug c.response A client is diagnosed with anxiety disorder is ordered .there to help her RATIONALE: Ensuring the safety of the client and the nurse is the priority at this time.d. The nurse recognizes that this ?client has symptoms of what disorder a. a warning that immediate sedation can occur with a resultant . a reminder of the need to schedule blood work 1 week after .which occurs in 14 to 30 days RATIONALE: The client should be informed that the drug's therapeutic effect might not be achieved for 14 to 30 days. Therefore. calling by her name. a warning about medication-related incidence of . the nurse should approach the client cautiously while calling her name and talking to her calm. is reported effect of buspirone. The nurse should keep in mind that the client shouldn't be startled or overwhelmed.reported with this drug A client on the behavioural health unit tells a nurse that she . Aerophobia c.63 experiences palpitations. a warning about the drug's delayed therapeutic effect. and nausea while travelling alone.drop in pulse b. These symptoms have severely limited the client's ability to function and have caused her to avoid leaving home whenever possible. Neuroleptic malignant syndrome hasn't been . Blood level check aren't necessary. Agoraphobia . outside her home. trembling.neuroleptic malignant syndrome d. After explaining she is there to help. Hodophobia d. Thanatophobia b. Teaching instructions for buspirone should :include a. confident manner. Tachycardia. and telling her that the nurse is . the nurse should carefully observe the client's . Approach the client slowly speaking in a calm voice.
Keep the client sedated whenever possible c. the .detailed instructions . severe anxiety and fear . which nursing intervention ?should appear in this client's care plan . or fear. nausea and shortness of breath. an inability to concentrate. wandering. Provide the client with detailed instructions . For client with Alzheimer's disease. such as palpitations. Agoraphobia is commonly accompanied by physical symptoms.RATIONALE: Agoraphobia is a phobia. and disorientation.common in depression A client with Alzheimer's disease has a nursing diagnosis of .c. and hodophobia. Thanatophobia is the fear of death. the fear of air. aerophobia.environment . poor motor control. It's also commonly accompanied or preceded by panic attacks. and avoidance of open spaces accompanied by the concern that escape to safety would be difficult or embarrassing.65 Risk for injury relate to memory loss.d.b. depression and weight loss .64 :months.b. the nurse should provide single. tachycardia.d. insomnia and an inability to concentrate . Remove potential hazards from the client's . To prevent injury.a. and weight loss are . simple instructions rather than many .fear of travelling A client with agoraphobia has been symptom-free for 4 . and elevated blood pressure. such as bottles of hydrogen peroxide and benzoin. Physical signs and symptoms of phobias include profuse sweating. Classic signs and symptoms of phobias include . the nurse can help prevent injury to the client. Insomnia. withdrawal and failure to distinguish reality from fantasy RATIONALE: Phobias cause severe anxiety ( such as panic attack) that is out of proportion the threat that the feared object or situation represents.a. trembling. Use restraints at all times RATIONALE: By removing potential environmental hazards.
the client is referred to a psychiatric clinical nurse-specialist.66 being arrested for attempting to sell cocaine to an undercover police officer. jointly by the physician and the nurse RATIONALE: A contract written jointly by the client and the nurse most successfully promotes cooperation and consistent behaviour. hot and cold flashes.a. schizophrenia d. by the client alone . After determining that the client has experienced four similar episodes in the past month. The most effective contract. stay out of the sun . panic depression b. jointly by the client and the nurse . To promote client compliance the nurse should anticipate that the contract will be :written . choking. depression c. and shaking or trembling.and the type least likely to allow for manipulation and misinterpretation. c. the nurse should :remind the client to .extreme physical exertion or life-threatening situations A nurse in a psychiatric inpatient unit is caring for a client with . vertigo and diaphoresis.68 generalized anxiety disorder. the nurse specialist suspects that :the client has a.c. by the nurse alone . Panic disorder also may cause dyspnea.d. the psychiatrists orders lorazepam ( Ativan ). 1 mg by mouth three times per day. palpitations. Panic disorder is confirmed by a history of three or more panic attacks within 3 weeks that are unrelated to . which results from acute anxiety.67 chest pain.A client is admitted to the inpatient adolescent unit after .describes the behavioural terms as . avoid caffeine. A behaviour contract is planned. obsessive-compulsive disorder RATIONALE: This client has classic signs and symptoms of panic disorder.a. feelings of unreality. During lorazepam therapy.b. When initial assessment indicates no physiological basis for three complaints.concretely as possible A client is admitted to the emergency department with the . As part of the client's treatment.
b.b. avoid aged cheese. An adequate salt intake is necessary for .70 disorders. Dystonia c. Nursing assessment reveals rigidity.Akathisia causes restlessness. Which life-threatening reaction do these findings ?suggest a. anxiety. Other dietary restrictions are unnecessary. Tardive dyskinesia syndrome b. Treatment for this client will likely involve medication. Tardive dyskinesia causes involuntary movements of the tongue.a. She is interviewing a new female client. The client reports that she hasn't menstruated in 3 months.d. d. a life-threatening reaction to neuroleptic medication that requires immediate treatment. mouth and muscles of the face. The client has lost a significant amount of weight over the past months and complains of being " sick to my stomach" when around food. hypertension. Requesting an order for a pregnancy test . Neuroleptic malignant d. Giving the client her newly ordered antidepressant medication .clients receiving lithium A client who takes neuroleptic medication for treatment of . and back muscles.69 chronic schizophrenia is admitted to the psychiatric unit. Akathisia RATIONALE: The client's sign and symptoms suggest neuroleptic syndrome. Requesting an as-needed medication for gastric distress RATIONALE: Although amenorrhea and gastric distress are common with anorexia nervosa.the potential to harm a developing fetus . fever. and jitteriness A nurse is working on a unit with individuals who have eating . Dystonia is characterized by cramps and rigidity of the tongue. maintain an adequate salt intake RATIONALE: Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam.. Staying out of the sun sunscreens is required when taking phenothiazine. neck. and diaphoresis. arms. . and many psychopharmacologic agents have . ruling out pregnancy is a priority.c. face. What is ?the priority nursing intervention . and legs. Involving the client in group activities .
one of the most difficult therapeutic techniques-conveys acceptance and gives the client an opportunity to reflect.72 .at bedtime .73 adequate rest and sleep.b. Lithium (Lithobid) is used to stabilize clients with bipolar disorder. a means of disapproval . reduce ritualistic behaviour in clients with obsessive.c. alleviate delusions for clients suffering from schizophrenia d. Some . a means of communicating patience and allowing the . Encourage environmental stimulation during the evening c.gestures :Propanolol ( Inderal) is used in the mental health setting to . the :nurse should a. intolerance or anger unless accompanied by hostile .client space in which to respond . To encourage restful sleep at night. therefore.b. to be avoided because it indicates intolerance and anger c. Encourage the client to take an antianxiety agent as needed .spends in bed during the day d. Talk with the client for a long time at night to reduce his . stabilize mood in the manic phase of bipolar illness . treat antipsychotic-induced akathisia and anxiety . it's used to treat antipsychotic-induced akathisia and anxiety.d. Antipsychotic are used to treat delusions. not therapeutic RATIONALE: Silence. It doesn't convey disapproval. Gently but firmly set limits on how much time the client .b. produces a sedating effect.antidepressants have been effective in treating OCD A depressed client in the psychiatric unit hasn't been getting . a potent beta.a.71 .adrenergic blocker.anxiety . (compulsive disorder (OCD RATIONALE: Propanolol.:Silence in therapeutic communication is .a.
".75 ?experiencing a panic attack a. Talking the client for a long time at night would interfere sleep and give the client attention for not sleeping.client Which nursing intervention is most helpful for a client .a. they .your bad habits d.anxiety through diversion c. Agreeing to give the client a smoke break would be detrimental to the client because it reinforces the client's acting-out behaviours.RATIONALE: Setting limits on how much time the client may spend in bed and what time the client must get up in the morning lets him know what is expected of him while conveying genuine concern for him. I'm busy c. Encouraging environmental stimulation in the evening would discourage rest and sleep at night.74 the nurse if he can have an additional smoke break because he's ?anxious. Staying with the client and remaining calm.aren't intended for use as sleep inducing agents A client is diagnosed with antisocial personality disorder asks .confident. I'll take you ". " Clients are permitted to smoke at designed times. Encouraging the client identify what precipitated the . Telling the client that she won't allow the extra smoke break because smoking is harmful is inappropriate because the nurse is lecturing the . and reassuring .You have to follow rules RATIONALE: Consistency is essential when dealing with antisocial clients. While most antianxiety agents have sedative adverse effects. Promoting the client's interaction with others to reduce . " Smoking is harmful to your health. " I have a few minutes. I don't want contribute to ". " I'm sorry but I can't take you. Which response by the nurse is best ". . He nurse assaying she is too busy avoids the client's attempt to manipulate.b.attack b. They disregard social norms and don't believe the rules apply on them.
This approach particularly important because the client already feels frightened and out of control. a nurse should treat all symptoms as indicators of possible pathology because a history of psychophysiologic illness doesn't rule out a purely physical . As the nurse accompanies the client to the radiology department. his feelings are very real. Tell the physician about the pain so that it's cause . Ignore the pain and focus on happy things RATIONALE: Initially.a. he looks around anxiously and states. Having someone remain with the client helps prevent him from feeling isolated and deserted.76 Upon reviewing the client's history. . " No one can hurt you here RATIONALE: Even though the client's thinking processes are distorted and irrational.c.d. " The FBI isn't here ". What should the nurse encourage the :client to do a. Reassuring intolerable stimuli by encouraging the client .c.weren't real . " You're illness is causing you to hear voices ".can be determined b.to stay in the room alone until his anxiety abates RATIONALE: A panic-stricken client requires the assistance of a calm person who can provide support and direction." What is ?the nurse's best response ". " It sounds like you're frightened ".77 tomography scan of the brain to rule out an organic etiology.d. The . Encouraging the client to identify what precipitated the attack is futile because the client's level of anxiety prevents . Remember all his previous " health problems" that .b.d.illness as a cause of a client's current symptoms A nurse is preparing a delusional client for a computed .him from focusing on precipitating factors The client reports severe pain in the back and joints. the nurse notes a diagnosis of depression and frequent hospitalization for somatic illness. Try to get more rest and use relaxation technique . " The FBI is coming to kill me.
When accompanying this client to he bathroom.d.c.nurse should intervene by emphasizing with his emotions.b. The nurse :should . allow him to shave . such as communicating suicidal thoughts. Two parents discuss their unwillingness to accept their son's death. some individuals get " stuck " in particular stages of grief . telling him that o one can hurt him appeal to the logical reasoning .parent's relationship with their deceased child A nurse is caring for a client whose on close observation . and messages. may never be accepted. some deaths. Assuring the client that the FBI isn't present. these parents need to get more support from others in .death of a loves one unachievable RATIONALE: Although acceptance is considered to be the final stage of grief. some individuals find the idea of " accepting" the .his illness has impaired A nurse is working with a group of parents whose . Rather it would be beneficial for the nurse to explore the . The need for observation precludes the patient's right to privacy. and talking about death Important teaching for a client receiving risperidone . observe him RATIONALE: The nurse has the responsibility to continuously observe the acutely suicidal client.a. open the window and allow him to get some fresh air .78 children have died from cystic fibrosis.80 :(Risperdal) should include advising the client to .the group c. hoarding . :the nurse should . To insist that a parent should work toward this goal wouldn't likely be helpful.and need help in moving forward d.a. give him privacy in the bathroom . threats. The nurse should watch for clues. including out-of-life cycle deaths.medications. The group is talking about " acceptance ". telling the client that his illness is causing him to hear voices.79 for suicide. these parents are still in denial about their child's death b.
The client shouldn't double the drug dose. Chlorpromazine is also a antipsychotic drug.releases them for the duty of care d.a.V. Chlorpromazine ( Thorazine ) c.adverse effect of risperidone therapy Parents tell a nurse that they haven't met their goal of . notify the physician if he notices an increase in .82 ?aggressive client with schizophrenia a. Lithium carbonate (( Lithonate b.bruising RATIONALE: Bruising may indicate blood dyscracias. Arrange for respite care.aggravating the client's condition RATIONALE: A voluntary admission is preferred approach because it involves having the client recognize existing problems and facilitates the client treatment. however. Discuss what the family can do to chemically restrain .the client at home c. family members could be . is the durg of choice for acute aggressive psychotic behaviour. Amitriptyline (( Elavil RATIONALE: Haloperidol is administered I. maintain a therapeutic level by doubling a dose if he . what recommendation ?should the nurse make a. This drug doesn't irritate the stomach. or I. They report that the client poses a threat to their safety. Tell the parents that the client's behaviour .irritate the stomach . Haloperidol ( Haldol ) d. Chemical restrains would violate the client's rights to freedom from . and weight gain isn't . discontinue the drug if he gains weight d.mental health facility b.c. it . Based on this information. Evaluate the client for voluntary admission to a .misses a dose b. so notifying the physician about increased bruising is very important.M.the use of restrains and seclusion What medication would probably be ordered for the acutely .81 home management of their son with schizoaffective disorder. be sure to take drug with a meal because it can severely .
psychologic.a. psychologic.83 This client tells the nurse that he uses illegal drugs for recreational purposes every weekend.a. .found have positive urine c. what should ?the nurse say a. the nurse's suggestion that the client consider how an error judgment could result in a serious accident reflects the principle of . structural and neurobiological factors d. " You may experience a complete loss of memory after the ". and amitriptyline is . " You're lucky that you haven't been randomly drug tested and ". " You'll be offered a strong sedative before the procedure ". " You may experience a time of confusion after the ".however. environmental factors and poor parenting .treatment d. . " Using drugs to relax and unwind jeopardizes your health and ". " This therapy will provide excellent symptom relief c.b.your ability to make decisions b. " I want you to think about how an error in judgement ".causes more pronounced sedation that haloperidol.85 a client to signed an informed consent for electroconvulsive therapy ?( ( ECT .b. and environmental factors is thought to cause schizophrenia.treatment RATIONALE: the nurse should explain to the client that he may experience a time of confusion following ECT as a result of electricity passing through the cerebral cortex and disrupting impulses. : There's a problem with you choosing to use drugs as a way to ".84 .used for depression A nurse assessing a client who is a pilot for an commuter airline. genetic factors leading to a faulty dopamine receptor .( nonmaleficence ( the obligation to do to no harm :Schizophrenia is caused by .c.cope with the stressors you experienced RATIONALE: Because her statement refers to those who could be harmed as a result of pilot's drug use. Studies of twins and adopted siblings have strongly implicated a genetic predisposition for schizophrenia.could cause a serious accident d. Lithium carbonate is useful in bipolar disorder. a reliable genetic marker hasn't be determined Which concept is most important for a nurse to communicate to . Although it's true that the client will be . a combination of biologic. Using the ethical principle of nonmaleficence to guide her interaction with the client. and environmental factors RATIONALE: A combination of biologic.
c.a.89 be in pain. Never .assessment within 1 hour . When licensed practitioner will do face-to-face . An alcoholic may enjoy an occasional social drink RATIONALE: Attendance at AA helps some individuals maintain strict abstinence from alcohol. Which fact .cure alcoholism c.essential component of informed consent Emergency restraints or seclusion may be implemented without .d.practitioner A nurse is caring for a client with antisocial personality disorder.b. A client with antisocial personality disorder tends to disregard rules and authority and to be socially irresponsible.87 Which statement is most appropriate for the nurse to make when ?explaining unit rules and expectations to this client a. If restraints are initiated without an order the client assess within 1 hour of application by a licensed.c. When a child is acting out RATIONALE: In a emergency. a client who is a threat to himself or others may be restrained without an order. .attend group therapy each day ". which is the foundation of any treatment for alcoholism. communicating this information isn't an .d. Which question by the nurse would best elicit ?information about the pain .to attend a group therapy each day b.88 ?should the nurse communicate to the client . family members must .d.expected to A nurse is working with a client who abuses alcohol. Abstinence is the basis for successful treatment b. "The other members of the health care team and I would like you ". Daily attendance at Alcoholics Anonymous ( AA) meeting will . "Please try to attend group therapy each day RATIONALE: Rules and explanations must be brief and clear and leave little room for misinterpretation. If a voluntary client wants to leave against medical advice .the family but isn't essential A client in the second stage of Alzheimer's disease appears to .participate . " You'll find you condition will improve much more quickly if you ". independent .offered a sedative. For treatment to be successful.86 ?a physician's order under which condition a. Participation in treatment by the family is beneficial to both the client and . The words " You'll be expected to attend group therapy each day" are concise and concrete and convey precisely what the client is . "You'll be expected to attend a group therapy each day ".
out of bed c. Fear d. Consulting the physician about substituting a different type of .trauma syndrome c.92 develops orthostatic hypontension while taking amitrptyline ?(( Elavil a. Dystonic reactions are typically acute and reversiblr.client When discharging a client after treatment for a dystonic .ended questions ( those that the client can answer with "yes" or "no") whenever possible. these aren't the most accurate nursing diagnosis for this . Advising the client to sit up for 1 minute before getting . the client shouldn't buy drugs on the street d.to prevent return of symptoms RATIONALE: An oral anticholinergic agent such as benztropine is commonly ordered to control and prevent the return of symptoms. although uncomfortable.term phases experienced by the victim of sexual assault.resolves d. A rape victim may also experienced fear.comprehension A client comes to the emergency department after being attack . Also repeating question aids . Instructing the client to halve the dosage until the problem . "Do you hurt?" ( pause) " Do you hurt RATIONALE: When speaking to a client with Alzheimer's disease. results of treatment are rapid and dramatic but may not last . Dystonic reactions can be .a. Hopelessness RATIONALE: The nursing diagnosis Rape. What is the most accurate nursing ?diagnosis for this client a.trauma syndrome refers to acute and long.c.b. anxiety. "Where is your pain located "?d.91 reaction. Specific nursing interventions can be planned on the basis of this diagnosis. the client must take benztropine ( Cogentin) as ordered . Informing the client that this adverse reaction disappear within 1 . avoid questions that requires the client to make choices. Rape. Anxiety b.life-threatening when airway patency is compromised Which nursing intervention is most appropriate if a client .week . the nurse should use close. and hopelessness.90 and sexually assaulted."?a. an emergency department nurse must ensure that the :client understands .antidepressant b. "Can you describe the pain "?c. "Where do you hurt "?b. this reaction isn't serious . however.
their liver metabolize drugs slowly.antidepressant A client who is victim of domestic violence tells the nurse she is . Which laboratory ?finding would alert the nurse to a potential problem a. the prescribing physician or an advanced practice nurse would have to adjust the chemical composition of TPN. Which statement ?describes how elderly clients react to medications . Decreased CD4 .94 administer a medication to an elderly client. They metabolize medications quickly d. They tolerate medication better because they're less active . Elderly clients typically need lower doses than younger clients. Use of drugs or alcohol to cope with victimization . The elevated glucose levels are expected in a client receiving TPN because of the high .93 contemplating leaving the relationship. In this cases. They're at increased risk for adverse effects .d.a.b. Nurses may then provide the victims with information and options to . c. the physician may decrease the dosage or order notriptyline.c. another tricyclic .c. History of previous victimization RATIONALE: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them.enable them to leave when they're ready A nurse is working on the psychiatric unit is preparing to .doesn't affect a person's reaction to medication A nurse is administering total parenteral nutrition ( TPN ) to a .a.95 client hospitalized with severe anorexia nervosa. Reasons for remaining in the abusive relationship b.concentration of glucose being administered .level b. Orthostatic hypotension commonly occurs with tricyclic depressant therapy.RATIONALE: To minimize the effects of amitriptylineinduced hypotension. the nurse should advise the client to sit up 1 minute before getting out of bed. Decreased magnesium level d.helpful resources . Which assessment should ?be the priority for the nurse . They need higher doses to elicit comparable medication .cell counts RATIONALE: A decreased magnesium level indicates continued malnutrition problems. Elevated phosphate . Cumulative effects can occur and increased the risk of adverse effects. not higher.response RATIONALE: As individuals age. Elevated glucose levels. Readiness to leave the perpetrator and knowledge of . Level of activity typically .
men older than age 45.98 ?trying to defuse a client's impending violent behaviour a.c.b.d.c.96 considered at highest risk for suicide. " The crisis team and I will escort you to the seclusion room RATIONALE: In many instances.b.d. physician. widowed. students. Discussing the health risk related to this medication RATIONALE: A nurse is mindful of the principal of informed consent when she discussed medication.a. The client has the right to adequate information about the drug as it relates to the treatment of .his condition Which nursing statement is most effective when the nurse is .d.a. . and young married men .with the drug . Alcohol abusers. a client asks a . " This is a good time for you to play cards with me ". Move the client to another room . the nurse can defuse impending violence by helping the client identify an express his feelings of anger and anxiety. What should the nurse do ?first . professionals.97 an outpatient drug and alcohol rehabilitation program. Teachers.unemployed persons. This approach may help the client verbalized his feelings rather than act on them. divorced persons.related health risk with the client. and persons who made previous suicide attempts.made previous suicide attempts . substance abusers . dentist and attorneys. Adolescents. such as physicians. Which group should the nurse ?emphasize a.99 nurse about moving to another room on the psychiatric unit because he has no longer feels " safe ". widows.injury should the client suddenly become violent After learning that a roommate is HIV-positive.angry ".c. Writing down medication information for the client b. Close interaction activity may place the nurse at risk for . and persons who . persons who are depressed A physician orders naltexone ( ReVia) for a client participating in .A nurse is teaching a new staff members about groups . Talking about how this drug prevents aggressive behaviour . men older than age 45. " Let's talk about what happened to make you this ". and separated persons. Do you feel you need to be alone in your room ". Which action reflects the nurse's knowledge about this medication and the ?client's informed consent . and persons living in rural area RATIONALE: Studies of those who commit suicide reveal the following higher risk groups: Adolescents. Depressed persons. divorced. Telling this client about the problems other the clients have had .
A.100 ?Which ECG change can result from amitriptyline ( Elavil) therapy a. these electrolytes are necessary for cardiac functioning.c. Move the client's roommate to a private room d. remaining calm and medicating as needed. . B. Appropriate nursing interventions for an anxiety attack include using short sentences. Total abstinence is the only effective treatment for alcoholism. Presence of U waves c.aren't typically by amitriptyline therapy :Set 2 1. 10. C. as needed A nurse is evaluating a client's electrocardiogram ( ECG ).or for his roommate RATIONALE: To intervene effectively. 2.move wouldn't be therapeutic. Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior. such as communicating suicidal thoughts. C. 14. hoarding medications and talking about death. Depressed ST segment d. A. D. and a prolonged PR interval . 12. With depression. gustatory. A. . Limiting unnecessary interaction will decrease stimulation and agitation. A. D. 8. 5.b. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. U waves. C. decreasing stimuli. An adult age 31 to 45 generates new level of awareness. 16. there is little or no emotional involvement therefore little alteration in affect. 9. Ask the client to describe his fears . Hallucinations are visual. A. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. These clients often hide food or force vomiting. the nurse may move the client or roommate or explain why such . After exploring his fears. Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. a depressed segment. 13. B. 7. B.. 11. C. tactile or olfactory perceptions that have no basis in reality. Widening QT interval b. such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles. Neuromuscular Blocker. Explain that such a move wouldn't be therapeutic for the client . Establishing a consistent eating plan and monitoring client’s weight are important to this disorder. the nurse must first understand his fears. 15. staying with the client. B.. demonstrated by a widening QT interval on the ECG. 4. therefore they must be carefully monitored. Prolonged PR interval RATIONALE: Amitriptyline therapy can cause a conduction delay. auditory. and messages. Delusion of grandeur is a false belief that one is highly famous and important. Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them. 6. 3. The Nurse should watch for clues. These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure. D. The Nurse has a responsibility to observe continuously the acutely suicidal client.
30. The nurse would most likely administer benzodiazepine. 41. A. Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits. C. Depression usually is both emotional & physical. nausea. B. Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder. C. Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message. Moving to a client’s personal space increases the feeling of threat. B. Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially 27. The autistic child repeat sounds or words spoken by others. A. B. 24. abdominal cramps and backache. 39. C. fever. least stressful and least anxiety producing. 31. The nurse presence may provide the client with support & feeling of control. 28. D. The natural tendency is to counterattack the threat to self image. Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client. The client statement is an example of the use of denial. Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide. which increases anxiety. 20. 23. D. 29. Vomiting and diarrhea are usually the late signs of heroin withdrawal. Serving coffee top the client may add to tremors or wakefulness. D. D. D. 19. 36. The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self. 37. 25. Children have difficulty verbally expressing their feelings. The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action. A. such as temper tantrums. 35. A. the client is likely to feel defensive because the question is belittling. Dental enamel erosion occurs from repeated self-induced vomiting. A consistent approach by the staff is necessary to decrease manipulation. D. D. A. 26. These are the major signs of anorexia nervosa. A person with this disorder would not have adequate self-boundaries. B. 32. 40. Discussion of the feared object triggers an emotional response to the object.17. The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. D. 34. 22. 18. C. along with muscle spasm. such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease. Any suicidal statement must be assessed by the nurse. 21. a defense that blocks problem by unconscious refusing to admit they exist. 33. A simple daily routine is the best. 38. . When the staff member ask the client if he wonders why others find him repulsive. repetitive. Weight loss is excessive (15% of expected weight). D. B. may indicate underlying depression. C. Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. A. The expression of these feeling may indicate that this client is unable to continue the struggle of life. acting out behavior.
In an emergency. dependence. Clients who are withdrawn may be immobile and mute. immaturity. II. The nurse facilitates communication with the client by sitting in silence. D. insecurity and jealousy. D. . D. repeated interventions. B. those that are fermented. Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses. aged. C. asking open-ended question and pausing to provide opportunities for the client to respond. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. A. the nurse should reinforce reality with the client. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation. 49. Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner. 43. often without finishing one idea. the length of the relationship should be discussed in terms of its ultimate termination. negative feelings about the future. 50. Flight of ideas is speech pattern of rapid transition from topic to topic. 46. and is unable to make decisions. The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room. blurred vision. Communication with withdrawn clients requires much patience from the nurse. has decreased energy. This will positively affect the client’s self-esteem. C. 47. The client with depression is preoccupied. Electroconvulsive therapy is an effective treatment for depression that has not responded to medication. 2. B. 3. The nurse should initiate brief. It is common in mania. 7. When the nurse and client agree to work together. 1. 4. a contract should be established. D. chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least 2 years. 6. or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur. and assists the client with personal hygiene to preserve his dignity and self-esteem. lives saving facts are obtained first. Dysthymia is a less severe.42. C. frequent contacts throughout the day to let the client know that he is important to the nurse. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self image. The nurse presents the situation. 44. dry mouth & constipation. When hallucination is present. Personal characteristics of abuser include low self-esteem. A. C. 45. B. and require consistent. 8. “It’s time for a shower”. D. pickled. 48. Foods high in tyramine. B. which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention. B. 5. Anticholinergic effects. C. A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
13. Attending activity with the nurse assists the client to become involved with others slowly. 10. drawn attention to self. 20. This client dramatizes events. Personality disorders are chronic lifelong patterns of behavior.” Indicates a lessening of suicidal ideation and improvement in the client’s condition. The nurse would use role-playing to teach the client appropriate responses to others and in various situations. Generally. B. although it can occur in either schizotypal personality disorder or borderline personality disorder. acute episodes do not occur. 12. prognosis for recovery is unfavorable. 14. 15. and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings & learn to express them appropriately. A. although they typically experience relationship and occupational problems related to their inflexible behaviors. A crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method & the delivery of the lethal impact of the method. Monitoring of vital signs provides the best information about the client’s overall physiologic status during alcohol withdrawal & the physiologic response to the medication used. They provide education about the biochemical etiology of psychiatric disease to reduce. Using exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur. D. not increase family guilt. Generally. thereby dispelling the delusion. Psychotic behavior is usually not common. C. D. 18. D. Psychoeducational groups for families develop a support network. kindness & gentle suggestion to improve social skills & interpersonal relationship. Because these disorders are enduring and evasive and the individual is inflexible. Although all the actions indicate improvement. 21. C. D. . An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. The statement “I don’t think about killing myself as much as I used to. Distress can occur based on other people’s reaction to the individual’s behavior. the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors. 11. 17. 19. The client with schizotypal personality disorder needs support. C. C. C. the individual does not seek treatment because he does not perceive problems with his own behavior. Allowing the client to be the first to open the cart & take a tray presents the client with the reality that the nurses are not touching the food & tray. unless labeling clearly indicates that the product does not contain alcohol. Antiseptic mouthwash often contains alcohol & should be kept in locked area. 16. A.9. B. these individuals make marginal adjustments and remain in society. The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties. The nurse would explain the negative reactions of others towards the client’s behaviors to make the clients aware of the impact of his seductive behaviors on others.
D. 25. the nurse would be especially alert for the possibility of respiratory failure. 23. 33. C. 27. B. The client must recognize the existence of the sub personalities so that interpretation can occur. A. and is associated with cocaine use. C. An acid environment aids in the excretion of PCP. After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefully. . withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe. Barbiturates are CNS depressants. secondary gain. A. A. The longer the client is free of drugs. 38. D. A. dependency and reinforcement of negative behavior while maintaining the client’s worth. D. the better the prognosis is. 39. hospitality. almost devoid of negative or undesirable features emerges. 28. the clients intellectual functions by providing anopportunity to use them. because the drug is short acting & respiratory depression may recur after its effects wear off. The best measure to determine a client’s progress in rehabilitation is the number of drug. D. 26.hallucinations & cognitive impairment. 29. 24. B. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5. and rest. C. The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms. 34. Respiratory failure is the most likely cause of death from barbiturate over dose. A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors. The nurse’s response is not therapeutic because it does not recognize the client’s needs but tries to make the client feel guilty for being demanding. B. C. B. An aloof. This action maintains for as long as possible. continuous process until a mental image of the dead person. The withdrawn pattern of behavior presents the individual from reaching out to others for sharingthe isolation produces feeling of loneliness. Individuals with anorexia often display irritability. 31. The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process. emotional distance. 36. This provides support until the individuals coping mechanisms and personal support systems can be immobilized. detached. 32. painful. 37. The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dinning room to decrease manipulation. The client in a manic episode of the illness often neglects basic needs. 40. Resolving a loss is a slow. C. including delusions. The feeling of bugs crawling under the skin is termed as formication.5 & accelerate excretion. 30. 35. Depressed clients demonstrate decreased communication because of lack of psychic or physical energy. and a depressed mood. these needs are a priority to ensure adequate nutrition.22.free days he has. fluid. B. A.
Alcohol is a central nervous system depressant. 45. B. . 48. Projection is a mechanism in which inner thoughts and feelings are projected onto the environment. This will help the client develop self-esteem and reduce the use of paranoid ideation. Regression is a way of responding to overwhelming anxiety. 49.41. C. The usual age of onset of schizophrenia is adolescence or early childhood. 46. 44. C. 42. seeming to come from outside the self rather than from within. 50. The fetal position represents regressed behavior. Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence. A. This provides a stimulus that competes with and reduces hallucination. B. B. Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. D. D. Somatic delusion is a fixed false belief about one’s body. A. C. 47. These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia. These symptoms are the body’s neurologic adaptation to the withdrawal of alcohol. 43.
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