Mental Health NCLEX EXAM- QUESTIONS AND ANSWERS.REVISED AND VERIFIED TO ACE YOUR STUDY

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Mental Health NCLEX EXAM- QUESTIONS AND ANSWERS. 1. The home care nurse is visiting an older client whose spouse died 6 months ago. Which behavior by the client indicates ineffective coping? 2. A... client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? 3. When the mental health nurse visits a client at home, the client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this client? 4. A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 5. A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing? 6. A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 7. On review of the client's record, the nurse notes that the mental health admission was voluntary. Based on this information, the nurse anticipates which client behavior? 8. When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 9. The nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? 10. The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply. 11. A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? 12. A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship? 13. The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 14. The nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. What is the nurse's role during the termination stage of group development? 15. Which are characteristics of the termination stage of group development? Select all that apply. 16. When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse understands that which is the purpose of this approach? 17. The nurse understands that which best describes Gestalt therapy? 18. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? 19. Which describes the primary focus of milieu therapy? 20. While being treated, a client is introduced to short periods of exposure to the phobic object while in a relaxed state. What term is used to describe this form of behavior modification? 21. A client is planning to attend Overeaters Anonymous. Which statement by the client indicates a need for additional information regarding this self-help group? 22. What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 23. Which type of therapeutic approach has the characteristic that all team members are seen as equally important in helping clients meet their goals? 24. A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 25. A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 26. A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 27. When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 28. A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing? 29. The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 30. A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. Which condition will be the focus of this consult? 31. A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 32. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 33. The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care? 34. The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 35. The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention? 36. The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 37. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 38. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1 39. Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 40. The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 41. A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 42. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply. 43. The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 44. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 45. The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 46. The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse? 47. A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 48. The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 49. The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event? 50. The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, what is the most appropriate question? 51. The nurse is developing a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 52. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 53. A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response? 54. The nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time? 55. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 56. The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action? 57. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 58. The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 59. The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 60. A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. What is the most appropriate nursing response? 61. A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 62. A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. 63. The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 64. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 65. The nurse is performing an assessment on a client with dementia. Which data gathered during the assessment indicates a manifestation associated with dementia? 66. The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 67. A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan on responding to the client's statement? 68. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 69. A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 4. "This form of therapy provides a negative reinforcement when the stimulus is produced." 70. The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 71. A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 72. The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority problem for this client? 73. The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care? 74. Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide? 75. Which client is most at risk for committing suicide? 76. A nursing instructor teaches a group of nursing students about violence in the family. Which statement by a student indicates a need for further teaching? 77. A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the day before ECT includes ensuring that the client follows which guideline? 78. A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy? 79. The nurse is performing an admission assessment on a client at high risk for suicide. The nurse should prepare to ask the client which assessment question to elicit data related to this risk? 80. The nurse in the mental health unit is performing an assessment in a client who has a history of multiple somatic complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? 81. A mental health nurse in a psychiatric unit is meeting with a client who has a long history of acting out and violent behavior. The client also is known to have abused drugs on numerous occasions. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to go straight." Which response by the nurse would be therapeutic? 82. A client with a diagnosis of depression has been meeting with the mental health nurse for therapy sessions for the past 6 weeks. During the session the client says to the nurse, "I lost my job this week, and I'm going to be evicted from my apartment if I can't pay my bill. The only person that I have is my daughter, but I don't want to burden her with my problems." Which response by the nurse would be therapeutic? 83. During a therapy session with a client with paranoid disorder, the client says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would be therapeutic? 84. The nurse in the mental health unit is assigned to care for a female client with a diagnosis of acute depression. In communicating with the client, which statement would be appropriate for the nurse to make? 85. The nurse is planning care for a client with bipolar disorder who is experiencing psychomotor agitation. Which activity should the nurse plan for this client? 86. The nurse is developing a plan of care for a client with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply. 87. The nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes that the client's emotional responses to situations occurring throughout the day are incongruent with the tone of the situation. The nurse should document the findings using which description of the client's behavioral response? 88. A mental health nurse notes that a client with schizophrenia is exhibiting an immobile facial expression and a blank look. Which should the nurse document in the client's record? 89. The nurse is developing a plan of care for the client with a diagnosis of paranoia and should include which interventions in the plan of care? Select all that apply. o 5. Use simple and clear language when communicating with the client. 90. The nurse is preparing a client for electroconvulsive therapy (ECT), which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. o 4. Withhold food and fluids for 6 hours before the treatment. 91. A hospitalized client is receiving clozapine (Clozaril) for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 92. A client has been prescribed disulfiram (Antabuse). Before giving the client the first dose of this medication, what should the psychiatric home health nurse determine? 93. A home care nurse making an initial home visit notes that a client is taking donepezil hydrochloride (Aricept). The nurse questions the client's spouse about a history of which disorder that is treated with this medication? 94. The nurse is caring for a client with a diagnosis of agoraphobia. When communicating with the client about the disorder, the nurse should expect the client to describe which behavior? 95. A client recently admitted to the hospital in the manic phase of bipolar disorder is dehydrated, unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. The nurse determines that which intervention is most appropriate for these complaints? 96. A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement bestdescribes the nurse's obligation to the client? 97. The mental health nurse is reviewing the discharge plan for a hospitalized client. In reviewing the plan, the nurse recognizes that which is the most prominent problem in the management of a client with a mental health problem in the community? 98. During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristic of bulimia? 99. The mental health nurse is talking to a client who has been diagnosed with posttraumatic stress disorder. During the conversation, the nurse notes that the client is exhibiting a paranoid stare and that he begins to pace and fidget. What is the appropriate nursing intervention? 100. The nurse is reviewing the record of a client admitted to the mental health unit. The nurse notes documentation that the client experiences flashbacks. What diagnosis should the nurse expect to be documented for this client? 101. The nurse is admitting a client with a diagnosis of posttraumatic stress disorder to the mental health unit. The client is confused and disoriented. During the assessment, what is the nurse's primary goal for this client? 102. The nurse in the mental health unit is having a conversation with a client diagnosed with posttraumatic stress disorder. The client seems upset and looks anxious. What is the appropriate nursing statement the nurse should make to the client? 103. A client with depression is scheduled to receive three sessions of electroconvulsive therapy (ECT). The client asks the nurse about the length of time it will take for improvement in the condition. The nurse should tell the client he or she will see improvement approximately how long after the three treatments? 104. A client has been diagnosed with major depression. The nurse notes that the client is not eating adequately and at times refuses to eat. What should the nurse plan to do to meet the client's nutritional needs? 105. The health care provider has prescribed medication therapy for a client with an alcohol abuse problem to assist in the maintenance of sobriety. The nurse reviews the client's record and expects to note that which medication has been prescribed? 106. The mental health nurse is caring for a client with a social phobia. The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse that she cannot sing and refuses to attend. What is the appropriate nursing response? 107. The nurse is monitoring a client who has been placed in restraints because of violent behavior. When should the nurse determine that it will be safe to remove the restraints? 108. The mental health nurse is conducting a group therapy session and is monitoring a client with a diagnosis of agoraphobia who has been attending the sessions for several months. The nurse notes that the client is cooperative, sharing with peers, and making appropriate suggestions during group discussions. How should the nurse interpret this behavior? 109. The nurse is preparing a client for electroconvulsive therapy (ECT). The family of the client asks the nurse about this treatment. The nurse responds, knowing that which statements are accurate regarding this treatment? Select all that apply. 110. The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar? 111. A 15-year-old client who is pregnant and unwed tells the nurse, "My life was unbearable before I met Johnny. My mother beats me up every day, and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make? 112. A 10-year-old girl who has been referred for evaluation for drawing sexually explicit scenes in her textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms? 113. During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't help wondering if he killed her, but the police have eliminated him as a suspect." Which statement is a therapeutic nursing response? 114. The nurse is assessing a client in the coronary care unit (CCU) who seems to fluctuate in his ability to focus during the day. On the basis of this assessment, which client problem should the nurse suspect? 115. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all the health care provider's fault. I have done everything that he has asked me to do!" How should the nurse interpret the client's statement? 116. The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, knowing that which is the maximum number of group members that can be included? 117. A nurse assists a client with a diagnosis of obsessive-compulsive disorder (OCD) in his preparations for bedtime. One hour later the client calls the nurse and says that he is feeling anxious; he asks the nurse to sit and talk for a while. Which is the appropriate initial nursing action? . 118. A nurse is planning care for a group of clients on a mental health unit. The nurse notes that most of the assigned clients require interventions commonly used to treat anxiety disorders. Such antianxiety interventions would be appropriate for which clients? Select all that apply. 119. A nurse is preparing to admit a client with a diagnosis of obsessive-compulsive disorder (OCD) to the mental health unit. The nurse would expect to note which behaviors in the client? 120. A nurse is performing an assessment on a client admitted to the mental health unit. The client tells the nurse that she cannot leave home without checking numerous times that the iron and coffee pot have been shut off. The client states that this activity makes her late for many functions and that she misses engagements on occasion because of it. The nurse would expect to note which anxiety disorder documented in the client's record? 121. A nurse is performing an assessment on a client admitted to the mental health unit. The nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior? 122. A mental health nurse asks a nurse orientee to describe the underlying pathophysiology associated with acts of compulsion, such as repeated hand washing, performed by clients with obsessive-compulsive disorder (OCD). The nurse determines that the orientee understands this disorder if the orientee identifies which characteristic of the client? 123. A nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action? 124. A nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). What is the nurse's first priority in the plan of care? 125. A nurse is preparing to develop a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse should plan to include which component as a priority in the nursing plan of care? 126. A nurse is reviewing the assessment findings documented in the chart of a client who is newly admitted to the mental health unit. The nurse notes that the client has experienced emotional turmoil and is exhibiting signs and symptoms that usually result from a loss of physical functioning, although no such loss can be confirmed medically. The nurse interprets these findings as indicating which condition? 127. The home health nurse visits an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which is the appropriate response? 128. A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initialaction with regard to the client's altered demeanor? 129. The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, if made by the client, would the nurse identify as necessitating further assessment on a priority basis? 130. A nurse is assessing a client in crisis and is determining the potential for self-harm. Which assessment data would indicate that the client is at very high risk for suicide? 131. The nurse is planning to instruct a mental health client and his or her family about the importance of medication compliance. The nurse should plan for which interventions that are associated with increased compliance? Select all that apply. 132. The nurse is planning care for a client who has been hospitalized for violent behavior and is at risk for harming others. Which intervention could potentially present a danger to the client, health care providers, and others on the nursing unit? 1. Facing the client when providing care 2. Assigning the client to a room at the end of the hall 3. Ensuring that a security officer is within the immediate area 4. Keeping the door to the client's room open when providing care to the client 2. Assigning the client to a room at the end of the hall 133. A nurse who is caring for a client with severe depression is planning activities for the client. The nurse goes to the activity room and finds a puzzle; a checkerboard game; a paint-by-number picture; and crayons, colored pencils, and paper for drawing. Which activity would be most appropriate for this client? 134. The nurse is developing a plan of care for a client who is scheduled to have electroconvulsive therapy (ECT). Which problem is a priority for this client? 135. A female client in a manic state emerges from her hospital room. She is topless and is making sexual remarks and gestures toward the staff and other clients. Which is the best initial nursing action? 136. A nurse is monitoring a group therapy session. During this session the members are identifying tasks and boundaries. The nurse determines that these activities are characteristic of which stage of group development? 137. When planning discharge care for a client with bipolar disorder, the nurse determines theneed for further teaching when the client makes which statement? 138. A client has consented to participate in Alcoholics Anonymous (AA) community groups after discharge from the hospital. The nurse is monitoring the client's response to the substance abuse sessions. Which statement by the client best reflects the development of an effective coping response style and effective processing of information for self-use? 3. "I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people." 139. A client who is on lithium carbonate will be discharged at the end of the week. In formulating a discharge teaching plan, the nurse should include which precaution? 4. Check with the psychiatrist before using any over-the-counter medications. 140. The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment? 3. "I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle." 141. The psychiatric home care nurse visits a client with a phobia who experiences panic attacks. The nurse teaches the client to use paradoxical intention and employs which method to teach the client this form of therapy? increasing the level of difficulty, and pairing relaxation with the gradual exposure to reduce his or her anxiety 2. Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor 142. A client tentatively diagnosed with a borderline personality disorder says to the nurse, "I don't know why I got my tattoo; it was for me. OK? Sometimes I do these things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the appropriate nursing response? 143. The nurse is reviewing the medical record of a client who received electroconvulsive therapy (ECT) in the past. Which assessment data would indicate to the nurse the presence of long-term retrograde amnesia in the client? 144. The mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter stashes food, eats all the foods that make her hyperactive, and hangs out with the "wrong crowd." In helping the mother prepare for her daughter's discharge, what instruction should the nurse provide? 145. The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which medical diagnosis, if noted on the client's record, would indicate a need to contact the health care provider scheduled to perform the ECT? 146. A woman who is a victim of family violence is now engaged in group therapy sessions. She begins yelling at another client during the therapy session and screams, "I can't listen to this. You people are no different from the ones at home." The client stands up and tips the chair over backward. What is the nurse's immediate action? 147. A client hospitalized in the mental health unit with depression is preparing to be discharged to outpatient status. The nurse is discussing termination and follow-up plans with the client. Which client statement would most concern the nurse about the client's discharge and indicate the need for follow-up treatment? 4. "I think I really couldn't have worked that job even if the man had given me the time he should have during the interview. It's just as well. I really didn't want a job where I had to work such long hours. But I had good reason to get depressed and end up here. But it all worked out. I really didn't want that job anyway." 148. During a support group session for battered women, a client says, "I was abused by my father and then my husband, so I finally stabbed my husband when he came after me, but no one on the jury believed me "cause my husband, the ‘big shot,' can lie to anyone and be believed." If no one in the group responds, which statement is the therapeutic response by the nurse? 1. "A pretty horrible experience for you to undergo. Does anyone in the group want to respond?" 149. The nurse is caring for a client with Alzheimer's disease who is having difficulty recognizing objects that are well known, including people. The nurse determines that the client is experiencing which problem? 150. A client with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse? 151. The night nurse reported to the nurse manager that a client was admitted to the mental health unit after attacking his father with an iron for interrupting him at his computer. During nursing rounds, this client interrupts the nurse manager and says, "I need to get out of here, so I can work on my computer project to save the world!" Which statement is a therapeutic response by the nurse manager? 152. The nurse is performing a mental status examination on a client, and the client states, "Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn't throw stones." Which interpretation by the nurse is appropriate? 153. The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic? 4. "Your health care provider wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?" 154. A nursing student is asked to identify suicide methods that are referred to as soft methods. The nursing instructor determines that the student understands the subject if he or she states that which is a soft method? 155. clinic is reviewing the records of the clients to be seen that day. The nurse determines that which client is at highest risk for suicide? 4. An 18-year-old alcohol- and drug-abusing youth who must tell his parents that he failed to pass an examination required for graduation from high school 156. The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic? 3. "Do you know that enabling creates codependency? Isn't viewing his failure as yours significant?" 157. A heroin-addicted client who is taking methadone hydrochloride (Dolophine) discontinues the methadone without consulting the health care provider. The client says to the nurse, "I thought I didn't need the methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything." Which statement by the nurse is therapeutic? 158. An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) freak me out. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the nurse would be therapeutic? 4. "Not all strategies for remaining sober are the best for everyone. It seems that you don't view yourself as having the same problem as others in the group." 159. A 37-year-old client who is recovering from benzodiazepine dependence says, "I think I've walked under a black cloud. I've lost so many people. First, my brother dies of the big C; then my husband leaves me for a 20-year-old bimbo. I wish I had a Xanax right now." Which statement by the nurse would be therapeutic? 4. "Can you tell me what you think the Xanax can do for you? Are there other things you used to do that might help you just as well?" 160. The husband of an alcohol-troubled wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic? 3. "Can you tell me more about that? You see yourself as being codependent with your wife?" 161. A 45-year-old client states that he used to drink a cocktail nightly after work and also had a drink with his meal. Now he has two drinks before dinner and two or three more drinks during his meal. As the client continues to describe his alcohol intake, the nurse discovers that he also has added a couple of drinks at night to help him sleep. Which is the most accurate assessment of his alcohol consumption? 162. A battered wife says, "My husband never beat me up, so I didn't think he was abusive even after he lost all our money through bad deals, bullying me into his schemes, gambling, womanizing, and now not holding a real job with benefits. I still let him refinance our mortgage, take money out of the bank, and put the house in his name." Which statement by the nurse is therapeutic? 4. "So you realize that there are many ways to erode someone's self-confidence and independence? Can you share with me some ways that you feel you can cope with this abuse?" 163. An 80-year-old resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse? 164. A client who is exhibiting psychotic behaviors is admitted to the psychiatric unit. In developing a plan of care, the nurse should identify which as the priority client problem? 1. Disturbed thought processes 165. The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client? 166. A client with a history of panic disorder comes to the emergency department and states to the nurse: "Please help me—I think I'm having a heart attack." What is the priority nursing action? 167. The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? 168. A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion? 2. Gathering subjective and objective assessment from the caregiver and the client 169. A client who has a history of being sexually assaulted is admitted to a psychiatric unit for self-mutilation. She is found sucking her thumb while rocking in her bed and does not respond to verbal communication. The nurse should recognize that this behavior demonstrates which coping mechanism? 170. A client is being evaluated for possible antisocial personality disorder. Which behavior is expected of a client with this disorder? 171. The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which issue? 172. Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of posttraumatic stress disorder? 173. A client admitted to the hospital at the beginning of the nursing shift with a diagnosis of alcohol dependence tells the nurse that she had her last drink 6 hours ago. The nurse expects which finding based on knowledge of time for appearance of withdrawal symptoms? 174. Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication? 175. Which mental health professional is responsible for the milieu in an inpatient psychiatric setting? 176. Which best describes the purpose of behavioral therapy? 177. The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 4. "It provides a negative reinforcement when the stimulus is produced." 178. Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which is the appropriate nursing response? 4. "It must be frightening to think that others want to hurt you." 179. A supervisor reprimands the nurse in charge of the nursing unit because the charge nurse has not adhered to the unit budget. Later that afternoon the charge nurse accuses the nursing staff of wasting supplies. What type of behavior is this an example of? 180. A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action? 3. Remain with the client until the anxiety decreases. 181. A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action? 3. Remain with the client until the anxiety decreases. 182. A woman comes into the emergency department following an assault. She presents with hyperventilation, pacing, rapid speech, and headache. Which level of anxiety should the nurse assess that the client is experiencing? 183. A nurse is developing a plan of care for the client who is upset following the loss of a job. The client is verbalizing concerns regarding the ability to meet financial obligations. Which is the appropriate client problem? 184. A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the effect on self. Which item should the initial nursing assessment focus on? 185. A clinic nurse is monitoring a client with anorexia nervosa. Which statement, if made by a client, should indicate to the nurse that treatment has been effective? 4. "My friends and I went out to lunch today." 186. A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for the possibility that which will occur? 187. Which is the primary goal of crisis intervention therapy? 1. Introduce new, effective coping methods to the client. 2 .Assess the client in order to identify the causative stressors. 3. Establish a sustainable therapeutic nurse-client relationship. 4. Assist the client in returning to the level of pre-crisis functioning. 4. Assist the client in returning to the level of pre-crisis functioning. 188. Which statement, if made by a client who has recently experienced an emotional crisis, ismost likely to assure the nurse that she has returned to her pre-crisis level of functioning? 3. "My boss tells me that I'm being considered for a promotion and a raise." 189. A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action? 1. Assessing the clients' need for supportive therapy 190. A small rural community has experienced a hurricane that has destroyed 65% of the homes and businesses in the area. Community mental health teams recognize that in the immediate post-disaster period, the most effective means of identifying individuals experiencing difficulty coping psychologically with the disaster is to take which action? 191. The nurse is preparing a care plan for a client exhibiting negative symptoms of schizophrenia. Which are indicative of negative symptoms? Select all that apply. 192. The nurse caring for a client diagnosed with schizophrenia should include which interventions into the plan of care to assist in managing the client's concrete thinking? 2. Present verbal instructions regarding expectations in single, simple commands. 193. The nurse understands that schizophrenia hinders a client's cognitive ability to appropriately process data from external stimuli. This dysfunctional processing can result in which problem? 194. During the admission assessment process, the nurse observes that a client with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor? 195. A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initial intervention? 196. The nurse is planning relapse prevention information for a client with schizophrenia who is being discharged. The nurse understands that it is important to ensure which primaryintervention in the plan whenever possible? 1. Including the client's support system in the teaching 197. A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right." Which is the best nursing response? 2. Identify recent behaviors or accomplishments that demonstrate the client's skills. 198. The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking two packs of cigarettes and drinking 10 cups of coffee daily. The nurse recognizes that which is the greatest risk for injury these behaviors present for this client? 3. Diminishing the effectiveness of psychotropic medication 199. The nurse should identify which best goal for a client experiencing hallucinations? 3. Facilitate the client's awareness that the hallucination is not the reality of the world. 200. The parents of a young adult have expressed concerns about the cognitive and emotional changes they have noted in their child. The nurse recognizes which assessment and diagnostic data as associated with the diagnosis of schizophrenia? Select all that 201. The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia? 202. The nurse should provide which information to the parents of a teenager about their child's new diagnosis of schizophrenia? 203. The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? 1. Coffee, tea, and soda consumption should be limited. 204. Which statement made by a severely depressed client requires the nurse's immediate attention? 1. "Feeling better really isn't important to me anymore." 205. The nurse is developing a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to include which priority information to the family? 1. Signs that the client may be considering suicide 206. Which are characteristics of seasonal affective disorder (SAD)? Select all that apply. o 6. Is a result of alterations in the available amounts of sunlight 207. When assessing a client's possible physical dependency on alcohol, the nurse should ask which priority question? 2. "How do you feel when you haven't had a drink all day?" 208. Which are the most likely characteristics of an alcohol abuser? Select all that apply. 209. The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers? 2. Is the cause of many drug overdose deaths 210. Which is a common outcome that results from the effect of methamphetamine abuse on the vascular system? 211. An adolescent has been prescribed an amphetamine to help manage a diagnosis of attention deficient hyperactivity disorder. To best minimize the risk of abuse and/or overdose, the nurse expects that the medication will be administered via which method? 212. A client who has a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor? 213. When admitting a client to the mental health unit who has a history of hallucinogenic drug use, the nurse should be prepared to manage which occurrences unique to abuse of this classification of drugs? 214. When discussing an individual's tendency to substance abuse, the nurse should identify which as a primary biological factor? 215. During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. Which is the most appropriate interpretation of the client's behavior? 216. A home health nurse is talking to the spouse of a client who is taking an antidepressant. The spouse says, "Now that my husband is responding to the antidepressant, the suicidal risk is over and you can stop making these home visits." After analyzing this statement, which is the appropriate nursing response?." 4. "I need to continue with my visits. Most suicides occur within 3 months after improvement begins, because the client now has the energy to carry out the suicidal intentions." 217. A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the appropriate nursing intervention? 218. The nurse assesses a client with an admitting diagnosis of bipolar affective disorder, mania. Which symptom presented by the client would require the nurse's immediate intervention? 2. Nonstop physical activity and poor nutritional intake 219. The nurse is performing an assessment on a client with dementia. Which would be a manifestation associated with dementia? 220. A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and notes that the client has poor nutritional intake. Which is the appropriate nursing intervention? 1. Weigh the client three times per week before breakfast. 2. Explain to the client the importance of a good nutritional intake. 221. A client with a diagnosis of major depression, recurrent, with psychotic features, is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with which problem? 222. The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? 223. The nurse has been working with a victim of rape in a clinic setting for the past 4 weeks. Which would be unrealistic as a short-term initial goal for this client? 4.The client will resolve feelings of fear and anxiety related to the rape trauma. 224. Which is the best approach for the nurse to use in crisis counseling? 1. Reassuring 225. A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which is the least realistic goal for this client? 3. The client will stop blaming himself for the lack of insurance. 226. The nursing care plan indicates a problem of self-directed violence and the risk for suicide,related to suicidal ideations with a plan. An expected outcome of this plan of care would be that the client does which? 4. Denies suicidal ideation and identifies options to deal with stressors 227. A client is admitted to the mental health unit with a problem related to grieving, because of the loss of a spouse. The client progresses well and is approaching discharge. Which is an appropriate outcome for the client? 2. The client verbalizes stages of grief and plans to attend a community grief group. 228. A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? 3. "I hear what you are saying, but I don't share your belief." 229. A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 2. "You seem very distressed over learning you have asthma." 230. A 63-year-old woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? 2. "It's OK to grieve and be angry with your daughter and anyone else for a time." 231. An older client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which is the therapeutic nursing response? 232. A hospitalized client with a diagnosis of schizophrenia who is experiencing delusions says to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? 4. "I don't know anything about the top man in the mob. Do you feel afraid that people are trying to hurt you?" 233. A nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which condition? 234. The nurse is monitoring a woman with a diagnosis of depression. Which behavior, if observed by the nurse, indicates that suicide precautions should be implemented for this client? 235. A client is found to have rape trauma syndrome. The nurse plans care for the client knowing that which occurs in this condition? 236. A nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center to plan activities that will meet the child's needs. Which should have the priority consideration in planning activities for the child? 237. A nurse is assigned to care for a chemically dependent client who has the potential for violent episodes. In planning to care for the client, which action by the nurse should receive priority? 238. A nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? 239. A nurse is developing a care plan that will include goals that will help the client achieve an optimal level of functioning and appropriate resource utilization. When the nurse enters the client's room, the client asks the nurse, "Could you ask the health care provider (HCP) to let me have a pass for the weekend?" Which response is appropriate that assists the client in achieving these goals? 4." I will call the HCP and find out if you can have a pass so that you can make your arrangements." 2. "When the HCP arrives on the unit, I will let them know that you have a question." 240. Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship? 4. Establishing the parameters of the relationship 241. A nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Which statement describes voluntary status? 242. A nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which best response should the nurse make? 243. A nurse in the emergency department is preparing to care for a client who has just been sexually assaulted. Which client behavior demonstrates denial? 1. The client is calm and quiet. 2. The client is blaming her sister for the incident. 244. The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses' station, becomes very loud and offensive, and demands to be seen by the health care provider (HCP) immediately. Which is the appropriate nursing intervention? 245. A nurse is developing a plan of care for a client with a psychotic disorder who is experiencing altered thoughts that include the belief food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings? 246. A mental health nurse has been meeting with a client on a weekly basis and over the past several weeks, the client has been consistently 15 minutes late. Which nursing action is appropriate regarding the client's lateness for the scheduled meetings? 3. Ask the client if something is going on that the client may have difficulty handling. 247. A mental health nurse who has been meeting with a client with a diagnosis of post-traumatic stress disorder is in the termination phase of the nurse-client relationship. The nurse notes that the client has been quiet and withdrawn. Which interpretation should the nurse make about the client's behavior? 3. A normal behavior that can occur during termination 248. A nurse is preparing for the arrival of a new client at a drug abusers' residential treatment center and prepares to explain to the client that the emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure. Which is the most likely focus of therapy of this residential center? 249. A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. Which describes the components of this form of therapy? 1. The client will take medication daily to control the condition. 2. The client will talk to himself or herself to control actions more effectively. 250. A nurse is conducting a group therapy session when a client who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. Which is the appropriate nursing action? 1. Tell the client that it is not safe to leave. 251. A nurse is helping to conduct a group therapy session. During the session, a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate initial nursing action? 1. Tell the client that he must leave immediately. 252. A nurse is preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care? 253. A nursing student is conducting a clinical conference and is describing the characteristics associated with milieu therapy. Which statement indicates an understanding of the focus of this form of therapy? 1. "Milieu therapy provides a cognitive approach to changing behavior." 254. A nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which therapeutic response should the nurse make to the client? 3. "Tell me more about what happened, and what causes you to feel like the rape just occurred." 255. A nurse is developing a plan of care for a client at high risk for suicide who was just admitted to the psychiatric unit. The focus of the plan is to promote a safe and therapeutic environment. Which intervention should the nurse include in the plan of care? 256. A client admitted to the mental health unit with depression states to the nurse, "My life has been such a failure. Nothing I do turns out right." Which therapeutic response should the nurse make? 4. "You seem very discouraged. Can you think of anything recently that went as you planned?" 257. A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize that which symptoms or behaviors require immediate intervention? 2. Constant physical activity and poor oral intake 258. A nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse? 259. A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on taking at this time? 260. A mental health nurse is assigned to care for a client with a diagnosis of acute schizophrenia. The nurse should use which approach when planning care for this client? 3. Provide assistance with grooming and nutrition until the client's thinking has cleared. 261. A mental health nurse is assigned to care for a client with a diagnosis of acute schizophrenia. The nurse should use which approach when planning care for this client? 1. Allow the client to set the goals for the plan of care. 262. A nurse is talking with a client who is actively hallucinating. The client is fearful that the voices will direct him to kill himself or will hurt him directly. Which therapeutic statement should the nurse make at this time? 1. "I can hear the voices too, but they are telling you to go to bed now." 263. A client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on an understanding of personality disorders, the nurse should determine that which problem is the priority? 264. A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). The client is calm, but the client's daughter is hypervigilant and anxious. The daughter says to the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which response by the nurse is therapeutic? 265. A nurse is assigned to a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech. The nurse should determine that which action is the priority of care at this time? 1. Providing safety for the client and other clients on the unit 266. A client diagnosed with catatonic stupor is lying on the bed, hidden under the sheets, in a fetal position. Which appropriate action should the nurse should take? 3. Sit beside the client in silence, with occasional open-ended questions. 267. A client who has sustained severe injuries in a motorcycle crash was diagnosed with intensive care unit (ICU) psychosis. Which indicates to the nurse that the client's status is improving? 268. A nurse caring for a client recently admitted to the hospital for anorexia nervosa enters the client's room and finds her in the middle of performing rapid exercises. Which action should be the priority? 269. A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens (DTs) should the nurse plan to continuously assess for? 270. A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which is the therapeutic response by the nurse? 3. "What aspects of this situation are the most difficult for you?" 271. A nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal? 3. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis 272. A nurse is working with a client who shows signs of benzodiazepine withdrawal. The nurse should suspect that the client has suddenly discontinued taking which prescribed medication? 273. A nurse is admitting a client who is in a state of starvation because of anorexia nervosa. Which roommate choice is least appropriate for this client? 274. A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. Which action should the nurse take at this time? 1. Call the nursing supervisor. 275. A nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal? 3. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis 276. A nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide if which is assessed? 1. Client exhibits impulsive behavior. 277. A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time? 1. "What is causing you to become agitated?" 278. A nurse is having a conversation with a depressed client on an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just weren't around." Which appropriate response should the nurse make at this time? 1. "You sound very unhappy. Are you thinking of harming yourself?" 279. A nurse should interpret that which comment by a client whose husband uses violence against her is consistent with the presence of low self-esteem commonly found with battered wife syndrome? 1. "I'm lucky to be married to a man who really loves me the way that he does." 280. A nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." Which response should the nurse make to the client? 1. "That doesn't sound like the real you talking!" 281. A client has been admitted to the inpatient psychiatric unit because the client has displayed violent behavior and is at risk for potentially harming others. What should the nurse avoid doing when caring for this client? 1. Admitting the client to a room near the nurses' station 2. Facing the client while speaking and providing nursing care 3. Arranging for a security officer to be available in the general area 282. A client who has attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. Which is the priority nursing action at this time? 283. A client admitted to the mental health unit with major depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior? 1. Continue to monitor the client's behavior from a distance. 2. Document that the client is adapting to the unit and is feeling safe. 284. A nurse is preparing a client for discharge who was hospitalized following a suicide attempt. The nurse evaluates that the client could benefit from further development of coping strategies if the client was overheard making which statement before discharge? 1. "I know now that I can't be all things to all people all the time." 285. A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. Which is the immediate nursing action? 1. Take the client's vital signs. 286. An acutely depressed client is receiving cognitive-behavioral therapy. The nurse is developing a plan of care for the client and includes interventions that focus on this type of therapy. Which interventions should the nurse include? Select all that apply. 1. Assisting the client to identify and test negative cognition 287. Which should a nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply. [Show More]

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