Psych/Mental Health Exit HESI – Saunders

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behavior by the client indicates ineffective coping?

1. Neglecting personal grooming
2. Looking at old snapshots of family
3. Participating in a senior citizens’ program
4. Visiting their spouse’s grave once a month

1. Neglecting personal grooming

Rational:
Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. The correct option is indicative of a behavior that identifies an ineffective coping behavior in the grieving process.

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?

1. “You have everything to live for.”
2. “Why do you see yourself as a failure?”
3. “Feeling like this is all part of being depressed.”
4. “You’ve been feeling like a failure for a while?”

4. “You’ve been feeling like a failure for a while?”

Rationale:
Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client’s experience and do not facilitate exploration of the client’s expressed feelings. In addition, use of the word “why” is nontherapeutic.

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?

1. “I see.”
2. “Really?”
3. “You’re having difficulty sleeping?”
4. “Sometimes, I have trouble sleeping too.”

3. “You’re having difficulty sleeping?”

Rationale:
The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client’s major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses since none encourage the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.

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?

1. Using open-ended questions and silence
2. Sharing personal preference regarding food choices
3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate nutrition

1. Using open-ended questions and silence

Rationale:
Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.

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?

1. Denial
2. Projection
3. Regression
4. Rationalization

1. Denial

Rationale:
Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. Regression allows the client to return to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.

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?

1. “Have you shared your feelings with your family?”
2. “I think we should talk more about your anger with your family.”
3. “You’re feeling angry that your family continues to hope for you to be cured?”
4. “You are probably very depressed, which is understandable with such a diagnosis.”

3. “You’re feeling angry that your family continues to hope for you to be cured?”

Rationale:
Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the client’s ability to discuss feelings openly with family members, it does not help the client discuss the feelings causing the anger. The nurse’s attempt to focus on the central issue of anger is premature. The nurse would never make a judgment regarding the reason for the client’s feeling; this is nontherapeutic in the one-to-one relationship.

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?

1. Fearfulness regarding treatment measures.
2. Anger and aggressiveness directed toward others.
3. An understanding of the pathology and symptoms of the diagnosis.
4. A willingness to participate in the planning of the care and treatment plan.

4. A willingness to participate in the planning of the care and treatment plan.

Rationale:
In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a client’s understanding of their illness, only of their desire for help.

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?

1. Monitor closely for harm to self or others.
2. Assist in completing an application for admission.
3. Supply the client with written information about their mental illness.
4. Provide an opportunity for the family to discuss why they felt the admission was needed.

1. Monitor closely for harm to self or others.

Rationale:
Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the client’s willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the illness is likely premature initially. The family may have had no role to play in the client’s admission.

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?

1. Planning short-term goals
2. Making appointment referrals
3. Developing realistic solutions
4. Identifying expected outcomes

2. Making appointment referrals

Rationale:
Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. The remaining options identify tasks appropriate for the working phase of the relationship.

The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply.

1. Restating
2. Listening
3. Asking the client, “Why?”
4. Maintaining neutral responses
5. Providing acknowledgment and feedback
6. Giving advice and approval or disapproval

1, 2, 4, 5

Rationale:
Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

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?

1. Denial
2. Projection
3. Rationalization
4. Intellectualization

1. Denial

Rational:
Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the client is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring one’s internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.

A client’s unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship?

1. Trusting
2. Working
3. Orientation
4. Termination

4. Termination

In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. The remaining options are not specifically associated with this issue of unresolved feelings.

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?

1. Exploring the client’s ability to function
2. Exploring the client’s potential for self-harm
3. Inquiring about the client’s perception or appraisal of why the rescue was unsuccessful
4. Inquiring about and examining the client’s feelings for any that may block adaptive coping

4. Inquiring about and examining the client’s feelings for any that may block adaptive coping

Rational:
The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client’s feelings and is client-focused. The remaining options do not directly focus on or address the client’s feelings.

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?

1. Acknowledging that the group has identified goals
2. Encouraging the accomplishment of the group’s work
3. Acknowledging the contributions of each group member
4. Encouraging members to become acquainted with one another

3. Acknowledging the contributions of each group member

Rationale:
In the termination stage, the group leader’s task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and assist each other to prepare for the future. Acknowledging that the group has identified goals and encouraging group bonding both occur during the initial stage. Encouraging accomplishment of the group’s work is appropriate during the working stage.

Which are characteristics of the termination stage of group development? Select all that apply.

1. The group evaluates the experience.
2. The real work of the group is accomplished.
3. Group interaction involves superficial conversation.
4. Group members become acquainted with each other.
5. Some structuring of group norms, roles, and responsibilities takes place.
6. The group explores members’ feelings about the group and the impending separation.

1 and 6

Rationale:
The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with each other, and some structuring of group norms, roles, and responsibilities takes place. During the initial stage, group interaction involves superficial conversation. During the working stage, the real work of the group is accomplished. During the termination stage, the group evaluates the experience and explores members’ feelings about the group and the impending separation.

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?

1. Providing a supportive environment
2. Examining intrapsychic conflicts and past issues
3. Emphasizing social interaction with clients who withdraw
4. Helping the client to examine dysfunctional thoughts and beliefs

4. Helping the client to examine dysfunctional thoughts and beliefs

Rationale:
Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. The remaining options, while therapeutic in certain situations, are not the focus of cognitive behavioral therapy.

The nurse understands that which best describes Gestalt therapy?

1. It emphasizes self-expression, self-exploration, and self-awareness in the present.
2. It promotes the individual’s comfort in the group, which then transfers to other relationships.
3. The therapist focuses on how irrational beliefs and thoughts contribute to psychological distress.
4. The therapist’s goal is to help others express their feelings toward one another during group sessions.

1. It emphasizes self-expression, self-exploration, and self-awareness in the present.

Rationale:
Gestalt therapy emphasizes self-expression, self-exploration, and self-awareness in the present. The client and therapist focus on everyday problems and try to solve them. Interpersonal group therapy promotes the individual’s comfort in the group, which then transfers to other relationships. In rational emotive therapy, the therapist focuses on how irrational beliefs and thoughts contribute to psychological distress. In Rogerian therapy, the therapist’s goal is to help others express their feelings toward one another during group sessions.

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?

1. Admitting to having a problem
2. Substituting other activities for gambling
3. Stating that the gambling will be stopped
4. Discontinuing relationships with people who gamble

1. Admitting to having a problem

Rationale:
The first step in the 12-step program is to admit that a problem exists. Substituting other activities for gambling may be a strategy but it is not the first step. The remaining options are not realistic strategies for the initial step in a 12-step program.

Which describes the primary focus of milieu therapy?

1. A form of behavior modification therapy
2. A cognitive approach to changing behavior
3. A living, learning, or working environment
4. A behavioral approach to changing behavior

3. A living, learning, or working environment

Rationale:
Milieu therapy, or “therapeutic community,” has as its focus a living, learning, or working environment. Such therapy may be based on numerous therapeutic modalities ranging from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu therapy may include behavioral approaches, the correct option describes its primary focus.

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?

1. Milieu therapy
2. Aversion therapy
3. Self-control therapy
4. Systematic desensitization

4. Systematic desensitization

Rationale:
Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Exposure is gradually increased until the anxiety about or fear of the object or situation has ceased. Milieu management refers to providing a safe, therapeutic environment and is applicable to not just this scenario. The remaining options are incorrect since they do not involve the intervention described.

A client is planning to attend Overeaters Anonymous. Which statement by the client indicates a need for additional information regarding this self-help group?

1. “The leader is a nurse or psychiatrist.”
2. “The members provide support to each other.”
3. “People who have a similar problem are able to help others.”
4. “It is designed to serve people who have a common problem.”

1. “The leader is a nurse or psychiatrist.”

Rationale:
The sponsor of a self-help group is an experienced member of the group. The nurse or psychiatrist may be asked by the group to serve as a resource, but would not be the leader of the group. The remaining options are characteristics of a self-help group.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?

1. Ask the client to leave the group for this session only.
2. Refer the client to another group that includes other manic clients.
3. Tell the client to stop monopolizing in a firm but compassionate manner.
4. Thank the client for the input, but inform the client that now others need a chance to contribute.

4. Thank the client for the input, but inform the client that now others need a chance to contribute.

Rationale:
If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed towards helping the client in a therapeutic manner.

Which type of therapeutic approach has the characteristic that all team members are seen as equally important in helping clients meet their goals?

1. Milieu therapy
2. Interpersonal therapy
3. Behavior modification
4. Rational emotive therapy

1. Milieu therapy

Rationale:
All treatment team members are viewed as significant and valuable to the client’s successful treatment outcomes in milieu therapy. Interpersonal therapy is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in his or her life. Behavior modification is based on rewards and punishment. Rational emotive therapy deals with the correction of distorted thinking.

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?

1. “I don’t believe this is true.”
2. “The guards are not out to kill you.”
3. “Do you feel afraid that people are trying to hurt you?”
4. “What makes you think the guards were sent to hurt you?”

3. “Do you feel afraid that people are trying to hurt you?”

Rationale:
It is most therapeutic for the nurse to empathize with the client’s experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

1. Move the client next to the nurse’s station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room.

2. Use an indirect light source and turn off the television.

Rationale:
Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses’ station may become necessary but is not the initial action.

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?

1. Encouraging quiet reading and writing for the first few days
2. Identification of physical activities that will provide exercise
3. No socializing activities, until the client asks to participate in milieu
4. A structured program of activities in which the client can participate

4. A structured program of activities in which the client can participate

Rationale:
A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too “restrictive” or offer little or no structure and stimulation.

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?

1. Suppressing feelings of anxiety
2. Identifying anxiety-producing situations
3. Continued contact with a crisis counselor
4. Eliminating all anxiety from daily situations

2. Identifying anxiety-producing situations

Rationale:
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

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?

1. Agoraphobia
2. Social phobia
3. Claustrophobia
4. Hypochondriasis

2. Social phobia

Rationale:
Social phobia is a fear of situations in which one might be embarrassed or criticized, such as the fear of speaking, performing, or eating in public. The person fears making a fool of oneself. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.

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?

1. Setting limits on the client’s behavior
2. Asking the client to leave the group session
3. Asking another nurse to escort the client out of the group session
4. Telling the client that they will not be able to attend any future group sessions

1. Setting limits on the client’s behavior

Rationale:
Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client’s behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client’s behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client’s right to receive treatment and is a threatening action.

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?

1. Psychosis
2. Repression
3. Conversion disorder
4. Dissociative disorder

3. Conversion disorder

Rationale:
A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person’s mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person’s ability to deal with life’s demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.

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?

1. Place the client in seclusion for 30 minutes.
2. Tell the client that the behavior is inappropriate.
3. Escort the client to their room, with the assistance of other staff.
4. Tell the client that their telephone privileges are revoked for 24 hours.

3. Escort the client to their room, with the assistance of other staff.

Rationale:
The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

1. Communicate expected behaviors to the client.
2. Ensure that the client knows that they are not in charge of the nursing unit.
3. Assist the client in identifying ways of setting limits on personal behaviors.
4. Follow through about the consequences of behavior in a nonpunitive manner.
5. Enforce rules by informing the client that they will not be allowed to attend therapy groups.
6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1, 3, 4, 6

Rationale:
Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client’s rights.

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?

1. Provide safety for the client and other clients on the unit.
2. Provide the clients on the unit with a sense of comfort and safety.
3. Assist the staff in caring for the client in a controlled environment.
4. Offer the client a less stimulating area to calm down in and gain control.

1. Provide safety for the client and other clients on the unit.

Rationale:
Safety of the client and other clients is the priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.

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?

1. “My medications aren’t likely to make me anxious.”
2. “I’ll go to support group and talk so that I don’t hurt anyone.”
3. “It’s not likely that I’ll get anxious or hear things if I get enough sleep and eat well.”
4. “When I begin to hallucinate, I’ll call my therapist and talk about what I should do.”

4. “When I begin to hallucinate, I’ll call my therapist and talk about what I should do.”

Rationale:
The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse should ask the client whether he or she has intentions to hurt him- or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.

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?

1. Ask direct questions to encourage talking.
2. Leave the client alone so as to minimize external stimuli.
3. Sit beside the client in silence with occasional open-ended questions.
4. Take the client into the dayroom with other clients so that they can help watch him.

3. Sit beside the client in silence with occasional open-ended questions.

Rationale:
Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client’s safety is not the responsibility of other clients.

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?

1. Increase socialization of the client with peers.
2. Avoid laughing or whispering in front of the client.
3. Begin to educate the client about social supports in the community.
4. Have the client sign a release of information to appropriate parties for assessment purposes.

2. Avoid laughing or whispering in front of the client.

Rationale:
Disturbed thought process related to paranoia is the client’s problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.

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?

1. Chess
2. Writing
3. Ping Pong
4. Basketball

2. Writing

Rationale:
Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.

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. Ask the client why he started taking illegal drugs.
2. Ask the client about the amount of drug use and its effect.
3. Ask the client how long he thought that he could take drugs without someone finding out.
4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

1. Ask the client why he started taking illegal drugs.

Rationale:
Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse’s bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse’s part and uses rationalization to avoid the therapeutic nursing intervention.

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.

1. Monitor vital signs.
2. Maintain NPO status.
3. Provide a safe environment.
4. Address hallucinations therapeutically.
5. Provide stimulation in the environment.
6. Provide reality orientation as appropriate.

1, 3, 4, 6

Rationale:
When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.

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?

1. “I no longer feel that I deserve the beatings my husband inflicts on me.”
2. “My attendance at the meetings has helped me to see that I provoke my husband’s violence.”
3. “I enjoy attending the meetings because they get me out of the house and away from my husband.”
4. “I can tolerate my husband’s destructive behaviors now that I know they are common with alcoholics.”

1. “I no longer feel that I deserve the beatings my husband inflicts on me.”

Rationale:
Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.

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?

1. Call the nursing supervisor.
2. Call security to block all exit areas.
3. Restrain the client until the health care provider (HCP) can be reached.
4. Tell the client that the client cannot return to this hospital again if the client leaves now.

1. Call the nursing supervisor.

Rationale:
Most health care facilities have documents that the client is asked to sign relating to the client’s responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and to sign the “against medical advice” document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client’s will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.

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.

1. Dental decay
2. Moist oily skin
3. Loss of tooth enamel
4. Electrolyte imbalances
5. Body weight well below ideal range

1, 3, 4

Rationale:
Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

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?

1. Interrupt the client and weigh her immediately.
2. Interrupt the client and offer to take her for a walk.
3. Allow the client to complete her exercise program.
4. Tell the client that she is not allowed to exercise rigorously.

2. Interrupt the client and offer to take her for a walk.

Rationale:
Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client’s preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that she is not allowed to complete the exercise program will increase the client’s anxiety.

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?

1. A client with pneumonia
2. A client undergoing diagnostic tests
3. A client who thrives on managing others
4. A client who could benefit from the client’s assistance at mealtime

2. A client undergoing diagnostic tests

Rationale:
The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others because this may contribute to sublimation and suppression of personal hunger.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?

1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscular rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in level of consciousness, hallucinations

4. Hypertension, changes in level of consciousness, hallucinations

Rationale:
Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

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?

1. “Why don’t you tell your wife about this?”
2. “What do you find difficult about this situation?”
3. “This is not the best time to make that decision.”
4. “I agree with you. You should get out of this situation.”

2. “What do you find difficult about this situation?”

Rationale:
The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.

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?

1. Normal behavior
2. Evidence of the client’s disturbed body image
3. Regression as the client is moving toward the community
4. Indicative of the client’s ambivalence about hospital discharge

2. Evidence of the client’s disturbed body image

Rationale:
Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client’s coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.

The nurse in the emergency department is caring for a young female victim of sexual assault. The client’s physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors?

1. Signs of depression
2. Normal reactions to a devastating event
3. Evidence that the client is a high suicide risk
4. Indicative of the need for hospital admission

2. Normal reactions to a devastating event

Rationale:
During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction. Options 1, 3, and 4 are incorrect interpretations.

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?

1. Witnessing a murder
2. The death of a loved one
3. A fire that destroyed the client’s home
4. A recent rape episode experienced by the client

2. The death of a loved one

Rationale:
A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster; it is unplanned or accidental.

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?

1. “With whom do you live?”
2. “Who is available to help you?”
3. “What leads you to seek help now?”
4. “What do you usually do to feel better?”

3. “What leads you to seek help now?”

Rationale:
The nurse’s initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.

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?

1. A crisis state indicates that the client has a mental illness.
2. A crisis state indicates that the client has an emotional illness.
3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis.
4. A client’s response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

4. A client’s response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

Rationale:
Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.

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?

1. “You need to stop that behavior now.”
2. “You will need to be placed in seclusion.”
3. “You seem restless; tell me what is happening.”
4. “You will need to be restrained if you do not change your behavior.”

3. “You seem restless; tell me what is happening.”

Rationale:
The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.

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?

1. “Have you talked to your family about this?”
2. “Everyone feels this way when they are depressed.”
3. “You will feel better once your medication begins to work.”
4. “You sound very upset. Are you thinking of hurting yourself?”

4. “You sound very upset. Are you thinking of hurting yourself?”

Rationale:
Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client’s feelings.

The nurse 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?

1. Initiate confinement measures.
2. Acknowledge the client’s behavior.
3. Assist the client to an area that is quiet.
4. Maintain a safe distance from the client.

1. Initiate confinement measures.

Rationale:
During the escalation period, the client’s behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

1. The adolescent gives away a DVD and a cherished autographed picture of a performer.
2. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room.
3. The adolescent becomes angry while speaking on the telephone and slams down the receiver.
4. The adolescent gets angry with her roommate when the roommate borrows the client’s clothes without asking.

1. The adolescent gives away a DVD and a cherished autographed picture of a performer.

Rationale:
A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of any adolescent.

The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action?

1. Administer an antianxiety agent.
2. Examine and treat the wound sites.
3. Secure and record a detailed history.
4. Encourage and assist the client to ventilate feelings.

2. Examine and treat the wound sites.

Rationale:
The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options 1, 3, and 4, may follow after the client has been treated medically.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, “I’m finally cured.” How should the nurse interpret this behavior as a cue to modify the treatment plan?

1. Suggesting a reduction of medication
2. Allowing increased “in-room” activities
3. Increasing the level of suicide precautions
4. Allowing the client off-unit privileges as needed

3. Increasing the level of suicide precautions

Rationale:
A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.

The nurse is 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?

1. One-to-one suicide precautions
2. Suicide precautions with 30-minute checks
3. Checking the whereabouts of the client every 15 minutes
4. Asking the client to report suicidal thoughts immediately

1. One-to-one suicide precautions

Rationale:
One-to-one suicide precautions are required for a client who has attempted suicide. Options 2 and 3 may be appropriate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in the correct option. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm himself or herself.

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?

1. Information regarding shelters
2. Instructions regarding calling the police
3. Instructions regarding self-defense classes
4. Explaining the importance of leaving the violent situation

1. Information regarding shelters

Rationale:
Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.

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?

1. “You need to try to be realistic. The rape did not just occur.”
2. “It will take some time to get over these feelings about your rape.”
3. “Tell me more about the incident that causes you to feel like the rape just occurred.”
4. “What do you think that you can do to alleviate some of your fears about being raped again?”

3. “Tell me more about the incident that causes you to feel like the rape just occurred.”

Rationale:
The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client’s feelings on hold. Option 4 places the problem-solving totally on the client.

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

1. Requesting that a peer remain with the client at all times
2. Removing the client’s clothing and placing the client in a hospital gown
3. Assigning a staff member to the client who will remain with the client at all times
4. Admitting the client to a seclusion room where all potentially dangerous articles are removed

3. Assigning a staff member to the client who will remain with the client at all times

Rationale:
Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client’s safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used.

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.

1. “I’m afraid of spiders.”
2. “I keep reliving the robbery.”
3. “I see his face everywhere I go.”
4. “I don’t want anything to eat now.”
5. “I might have died over a few dollars in my pocket.”
6. “I have to wash my hands over and over again many times.”

2, 3, 5

Rationale:
Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with posttraumatic stress disorder. The statement. “I’m afraid of spiders,” is more relative to having a phobia. The statement “I have to wash my hands over and over again many times” describes ritual compulsive behaviors to decrease anxiety for someone with obsessive compulsive disorder. Stating “I don’t want anything to eat now” is vague and could relate to numerous conditions.

The 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?

1. Adhering to the mandatory abuse-reporting laws
2. Notifying the case worker of the family situation
3. Removing the client from any immediate danger
4. Obtaining treatment for the abusing family member

3. Removing the client from any immediate danger

Rationale:
Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse’s immediate action?

1. Incessant talking and sexual innuendoes
2. Grandiose delusions and poor concentration
3. Outlandish behaviors and inappropriate dress
4. Nonstop physical activity and poor nutritional intake

4. Nonstop physical activity and poor nutritional intake

Rationale:
Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client’s mood is predominantly elevated, expansive, or irritable. All of the options reflect a client’s possible symptoms. The correct option clearly presents a problem, however, that compromises physiological integrity and needs to be addressed immediately.

The nurse is performing an assessment on a client with dementia. Which data gathered during the assessment indicates a manifestation associated with dementia?

1. Uses confabulation
2. Improvement in sleeping
3. Absence of sundown syndrome
4. Presence of personal hygienic care

1. Uses confabulation

Rationale:
The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being “wrong” to the client’s significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?

1. Engaging in immoral acts
2. Always reinforcing self-approval
3. Observing rigid rules and regulations
4. Having the need always to make the right decision

3. Observing rigid rules and regulations

Rationale:
Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety.

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?

1. Reassure the client that things will get better.
2. Tell the client that this is not true and that we all have a purpose in life.
3. Identify recent behaviors or accomplishments that demonstrate the client’s skills.
4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

3. Identify recent behaviors or accomplishments that demonstrate the client’s skills.

Rationale:
Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client’s feelings. Silence may be interpreted as agreement.

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?

1. An expected coping mechanism
2. An ineffective coping mechanism
3. A need to notify the hospital lawyer
4. An expression of guilt on the part of the client

1. An expected coping mechanism

Rationale:
The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client’s feelings, and the data in the question do not indicate that guilt is present.

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?

1. “This form of therapy can be applied to new situations.”
2. “An advantage of this technique is that change is likely to last.”
3. “Talking to oneself is a basic component of this form of therapy.”
4. “This form of therapy provides a negative reinforcement when the stimulus is produced.”

4. “This form of therapy provides a negative reinforcement when the stimulus is produced.”

Rationale:
Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?

1. Provide authority, action, and participation.
2. Display an attitude of detachment, confrontation, and efficiency.
3. Demonstrate confidence in the client’s ability to deal with stressors.
4. Provide hope and reassurance that the problems will resolve themselves.

1. Provide authority, action, and participation.

Rationale:
A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) “takes over” for the client (authority) who is not in control and devises a plan (action) to secure and maintain the client’s safety. When this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies.

A 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?

1. Begin to teach relaxation techniques.
2. Encourage the client to discuss the assault.
3. Remain with the client until the anxiety decreases.
4. Place the client in a quiet room alone to decrease stimulation.

3. Remain with the client until the anxiety decreases.

Rationale:
This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client’s level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

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?

1. Anxiety
2. Unrealistic outlook
3. Lack of ability to cope effectively
4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively

Rationale:
Lack of ability to cope effectively may be evidenced by a client’s inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers and although the client was experiencing anxiety, the client’s concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.

The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care?

1. Disrupted appearance because of weight
2. Inability to feed self because of weakness
3. Pain because of an inflamed gastric mucosa
4. Nutritional imbalance because of lack of intake

4. Nutritional imbalance because of lack of intake

Rationale:
The priority client problem for the client with anorexia nervosa is lack of intake and nutritional imbalance. Although the problems identified in options 1, 2, and 3 may be considerations in the plan of care for the client with anorexia nervosa, nutritional imbalance is the priority.

Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide?

1. “Discussing suicide with a client is not harmful.”
2. “Those clients who talk about suicide never do it.”
3. “Depressed clients are the only persons who commit suicide.”
4. “When a person talks about making suicide threats, the only thing the person wants is attention from family and friends.”

1. “Discussing suicide with a client is not harmful.”

Rationale:
An open discussion of suicide will not encourage a client to make a decision to commit suicide and in fact often will help to prevent it. Such a discussion offers the health care professional the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. Options 2, 3, and 4 are inaccurate statements regarding suicide.

Which client is most at risk for committing suicide?

1. A 75-year-old client with metastatic cancer
2. A 71-year-old client with a cardiac disorder
3. A 24-year-old client who just had an argument with her roommate
4. A 30-year-old newly divorced client who states she has custody of the children

1. A 75-year-old client with metastatic cancer

Rationale:
The person most at risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.

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?

1. “Abusers use fear and intimidation.”
2. “Abusers usually have poor self-esteem.”
3. “Abusers often are jealous or self-centered.”
4. “Abuse occurs more often in low-income families.”

4. “Abuse occurs more often in low-income families.”

Rationale:
Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the point at which their victims will do anything just to avoid further abuse. The statement that abuse occurs more often in lower socioeconomic groups is incorrect.

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?

1. Does not smoke at all
2. Receives no visitors and participates in limited unit activities
3. Reports to the clinic for blood draws and an electrocardiogram (ECG)
4. Is placed on nothing by mouth (NPO) status for 16 to 24 hours before the ECT

3. Reports to the clinic for blood draws and an electrocardiogram (ECG)

Rationale:
Before ECT, blood tests are performed and an ECG is done to determine a baseline status of the client. The nurse needs to explain the need for these preprocedures to the client. Maintaining *NPO status for 6 to 8 hours before treatment* is adequate; NPO status for 16 to 24 hours is not necessary. Some hospitals place clients on NPO status at midnight before ECT in the morning. Some clients who are on cardiovascular medication may be instructed to take their medicine with sips of water several hours before ECT. Options 1 and 2 are incorrect.

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?

1. “It uses positive reinforcement.”
2. “It uses negative reinforcement.”
3. “It increases social behaviors in the client.”
4. “It increases the level of self-care in the client.”

2. “It uses negative reinforcement.”

Rationale:
Operant conditioning entails rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach. Options 1, 3, and 4 are accurate characteristics of this form of therapy.

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?

1. “What are you feeling right now?”
2. “Do you have a plan to commit suicide?”
3. “How many times have you attempted suicide in the past?”
4. “Why were your attempts at suicide unsuccessful in the past?”

2. “Do you have a plan to commit suicide?”

Rationale:
When assessing for suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Although options 1, 3, and 4 are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide.

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?

1. Depression
2. Schizophrenia
3. Somatization disorder
4. Obsessive-compulsive disorder

3. Somatization disorder

Rationale:
Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.

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?

1. “You have said this many times before!”
2. “Tell me what makes you feel that you are ready.”
3. “I have not seen any changes in you to believe that you are ready to go straight.”
4. “I’m so glad to hear you talking this way. I will let your health care provider know.”

2. “Tell me what makes you feel that you are ready.”

Rationale:
Clients with a long history of acting out and violent behavior and those who have used drugs need to demonstrate motivation to change the behavior, not just verbalization of the behavior. The therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that indicate the change. The correct option is the only one that will provide this direction to the client.

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?

1. “Why did you lose your job?”
2. “There are homeless shelters available, and we will get you into one if you are evicted from your apartment.”
3. “If you get evicted from your apartment, we will commit you to the hospital, so you will have a place to eat and sleep.”
4. “Let’s talk about contacting your daughter. Wouldn’t you want to know if your daughter was having difficulty and try to help her if you could?”

4. “Let’s talk about contacting your daughter. Wouldn’t you want to know if your daughter was having difficulty and try to help her if you could?”

Rationale:
The therapeutic communication technique is clarification that attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client’s feelings and actions. Asking why a client lost a job is not directly related to the client’s feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client’s concerns and feelings on hold.

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?

1. “Your comment is inappropriate.”
2. “Thank you for noticing. I just bought this new perfume.”
3. “My hair has been a mess. I really needed to have it done.”
4. “We are not here to discuss how I look or smell. We are here to talk about you.”

4. “We are not here to discuss how I look or smell. We are here to talk about you.”

Rationale:
The therapeutic response by the nurse is the one that clarifies the content of the client’s statements and directs the client to the purpose of the session. The nurse should confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Option 1 may be judgmental and may provide an opening for a verbal struggle. Options 2 and 3 are social responses and could be misinterpreted by the client.

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?

1. “You look lovely today.”
2. “You’re wearing a new blouse.”
3. “Don’t worry-everyone gets depressed once in a while.”
4. “You will feel better when your medication starts to work.”

2. “You’re wearing a new blouse.”

Rationale:
A client who is depressed sees the negative side of everything. Telling the client that she looks lovely today can be interpreted as “didn’t look lovely last time we met.” Neutral comments such as that identified in the correct option will avoid negative interpretations. The client should not be told not to worry, that everyone gets depressed once in a while, or that he or she will feel better, because such statements are inappropriate.

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?

1. Reading letters and books in a quiet environment
2. Providing an activity such as checkers for the client
3. Involving the client in a card game with other clients on the unit
4. Including the client in a clay-molding class that is scheduled for today

4. Including the client in a clay-molding class that is scheduled for today

Rationale:
When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include volleyball, finger-painting, drawing, and working with clay. These activities provide an appropriate way for the client to discharge motor tension. Reading and simple card games are sedentary activities. Playing checkers requires concentration and more intensive use of thought processes.

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.

1. Assist the client in selecting foods from the food menu.
2. Offer high-calorie fluids throughout the day and evening.
3. Allow the client to eat alone in the room if the client requests to do so.
4. Offer small high-calorie, high-protein snacks during the day and evening.
5. Select the foods for the client to be sure that the client eats a balanced diet.

1, 2, 4

Rationale:
In caring for a client with depression whose nutritional intake is poor, the nurse should remain with the client during the meal. The nurse also should assist the client in selecting foods from the menu because the client is more likely to eat the foods that he or she likes. Offering small high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition.

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?

1. Flat affect
2. Bizarre affect
3. Blunted affect
4. Inappropriate affect

4. Inappropriate affect

Rationale:
An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client’s inner emotions.

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?

1. The client has a flat affect.
2. The client has an inappropriate affect.
3. The client is exhibiting bizarre behavior.
4. The client’s emotional responses exhibit a blunted affect.

1. The client has a flat affect.

Rationale:
A flat affect is manifested as an immobile facial expression or blank look. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client’s inner emotions.

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.

1. Provide a warm approach to the client.
2. Ask permission before touching the client.
3. Eliminate physical contact with the client.
4. Defuse any anger or verbal attacks with a nondefensive stance.
5. Use simple and clear language when communicating with the client.

2, 3, 4, 5

Rationale:
When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse’s intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.

The nurse 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.

1. Obtain an informed consent.
2. Have the client void before the procedure.
3. Remove dentures and contact lenses before the procedure.
4. Withhold food and fluids for 6 hours before the treatment.
5. Administer tap water enemas on the evening before the procedure.

1, 2, 3, 4

Rationale:
Enemas are not a component of the pretreatment care for a client scheduled for ECT. Options 1, 2, 3, and 4 are a part of the pretreatment plan. Additionally, the nurse should teach the client and family what to expect with ECT and allow the client to discuss his or her feelings regarding the procedure.

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?

1. Platelet count
2. Cholesterol level
3. Blood urea nitrogen
4. White blood cell (WBC) count

4. White blood cell (WBC) count

Rationale:
Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The WBC count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 3 are incorrect and unrelated to this medication.

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?

1. If there is a history of hyperthyroidism
2. When the last full meal was consumed
3. If there is a history of diabetes insipidus
4. When the last alcoholic drink was consumed

4. When the last alcoholic drink was consumed

Rationale:
Disulfiram is an adjunctive treatment for some clients with chronic alcoholism to assist in maintaining enforced sobriety. Because clients must abstain from alcohol for at least 12 hours before the initial dose, the most important assessment is when the last alcoholic intake was consumed. The medication should be used cautiously in clients with hypothyroidism, diabetes mellitus, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in persons with severe heart disease, psychosis, or hypersensitivity to the medication.

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?

1. Dementia
2. Schizophrenia
3. Seizure disorder
4. Obsessive-compulsive disorder

1. Dementia

Rationale:
Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer’s type. It increases concentration of acetylcholine, which slows the progression of Alzheimer’s disease. The other options are incorrect and are not indications for use of this medication.

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?

1. A fear of dirt and germs
2. A fear of leaving the house
3. A fear of speaking in public
4. A fear of riding in elevators

2. A fear of leaving the house

Rationale:
Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. Option 1 describes an obsessive-compulsive behavior. Option 3 describes a social phobia. Option 4 describes claustrophobia.

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?

1. Teach self-grooming skills.
2. Reward cleanliness with unit privileges.
3. Monitor the adequacy of the antipsychotic dosage.
4. Encourage frequent fluid intake and a high-fiber diet.

4. Encourage frequent fluid intake and a high-fiber diet.

Rationale:
Constipation is a common elimination problem with clients in a manic phase of bipolar disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic activity level. The symptoms listed in the question, dehydrated, unkempt, and abdominal fullness and discomfort, in combination with antipsychotic medications, are indicators of constipation. A high-fiber diet and increased fluids can reduce constipation.

A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement best describes the nurse’s obligation to the client?

1. The nurse must have the client go to the local mental health center daily for counseling.
2. The nurse must ask the client not to reveal suicidal plans if the information needs to be kept confidential.
3. The nurse cannot tell anyone what the client said and must strictly adhere to the professional duty for confidentiality.
4. The nurse must override the duty to observe confidentiality and notify the client’s health care provider (HCP) about the suicidal ideation.

4. The nurse must override the duty to observe confidentiality and notify the client’s health care provider (HCP) about the suicidal ideation.

Rationale:
In this situation, the nurse must override the duty to observe confidentiality and notify the client’s HCP about the client’s suicidal ideation. Option 1 is incorrect because the client is homebound. Option 2 is incorrect because the nurse has a professional obligation to intervene when a client tells the nurse about ideas or plans to harm himself or herself or others. Option 3 is incorrect because the nurse has a moral obligation to protect the client.

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?

1. The community’s opposition
2. The client’s noncompliance with medication therapy
3. The associated increased incidence of social problems
4. The family’s reaction to keeping the client in the community

2. The client’s noncompliance with medication therapy

Rationale:
Clients often forget to take their medications as scheduled, and this is the most prominent problem. Options 1, 3, and 4 may occur, but the problems described are not the most prominent and can be addressed and often controlled.

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?

1. Refusing to eat and excessive exercising
2. Eating only vegetables and fruits and fasting
3. Hoarding of food and difficulty controlling food intake
4. Eating a lot of food in a short period of time and misuse of laxatives

4. Eating a lot of food in a short period of time and misuse of laxatives

Rationale:
Eating binges and purging are the characteristic that would be seen in bulimia. Eating only certain types of foods may reflect a preference but does not indicate bulimia. Bulimic persons usually do not refuse to eat; rather, they binge and purge. Hoarding of food may indicate another problem.

The 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?

1. Allow the client to pace.
2. Escort the client to a quiet room.
3. Change the conversation to a less threatening subject.
4. Share the observation with the client and help the client to recognize his feelings.

4. Share the observation with the client and help the client to recognize his feelings.

Rationale:
Sharing observations with the client may help him recognize and acknowledge feelings. Allowing the client to pace may also allow him to get out of control. Moving to a quiet room or changing the subject will not help the client to recognize his behaviors and feelings.

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?

1. Anxiety
2. Agoraphobia
3. Schizophrenia
4. Posttraumatic stress disorder (PTSD)

4. Posttraumatic stress disorder (PTSD)

Rationale:
The major clinical manifestation associated with PTSD is client experience of flashbacks. Flashbacks are not specifically associated with anxiety, agoraphobia, or schizophrenia.

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?

1. Explain the unit rules.
2. Orient the client to the unit.
3. Stabilize the client’s psychiatric needs.
4. Accept the client and make the client feel safe.

4. Accept the client and make the client feel safe.

Rationale:
It is important to make a confused client feel safe. Explaining the unit rules and orientation to the unit are part of any admission process. Stabilizing psychiatric needs is a long-term goal.

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?

1. “Don’t worry so much.”
2. “I can see that you are upset.”
3. “Everything is going to be all right.”
4. “Why are you having so much trouble controlling your anxiety?”

2. “I can see that you are upset.”

Rationale:
The correct option is the only one that addresses the client’s feelings and concerns. Options 1 and 3 provide false reassurance and place the client’s feelings on hold. Option 4 is a nontherapeutic communication technique and will increase the client’s anxiety.

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?

1. 1 week
2. 3 weeks
3. 4 weeks
4. 8 weeks

1. 1 week

Rationale:
Health care providers generally administer ECT treatments three times a week, with an average series including 8 to 12 treatments. After three sessions of ECT, the client should start to demonstrate improvement in 1 week. Options 2, 3, and 4 are incorrect.

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?

1. Force foods and fluids.
2. Provide small, frequent meals.
3. Provide snacks and meals as requested.
4. Tell the client that social activities will be restricted unless food intake is increased.

2. Provide small, frequent meals.

Rationale:
A depressed client may eat small amounts of food because large amounts may seem overwhelming. If the client becomes overwhelmed, he or she may respond by withdrawing further. Providing snacks and meals when the client requests them will not ensure adequate nutritional intake. Forcing foods and fluids and telling the client that social activities will be restricted will cause further withdrawal by the client. Telling the client that social activities will be restricted also is a demeaning action.

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?

1. Clonidine (Catapres)
2. Disulfiram (Antabuse)
3. Pyridoxine hydrochloride (vitamin B6)
4. Chlordiazepoxide hydrochloride (Librium)

2. Disulfiram (Antabuse)

Rationale:
Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety. Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment of vitamin B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a benzodiazepine) that is used in the management of acute alcohol withdrawal symptoms.

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?

1. “You must go. You have no choice.”
2. “Why don’t you want to attend? What is the real reason?”
3. “The health care provider has prescribed this therapy for you.”
4. “You don’t have to sing at the session. You can listen and enjoy the music.”

4. “You don’t have to sing at the session. You can listen and enjoy the music.”

Rationale:
The correct option encourages the client to socialize and indicates that it is not necessary to sing. Option 2 asks why, and use of this word should be avoided. Options 1 and 3 imply a demand and do not address the client’s concern. The correct option is the only one that addresses the client’s concern.

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?

1. Administered medication has taken effect.
2. The client verbalizes the reasons for the violent behavior.
3. The client apologizes and tells the nurse that it will never happen again.
4. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.

4. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.

Rationale:
The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. Options 1, 2, and 3 do not ensure that the client has controlled the behavior.

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?

1. Manipulation
2. Improvement
3. Attention seeking
4. Desire to be accepted

2. Improvement

Rationale:
The behaviors identified in the question indicate improvement in the client’s condition. The question presents no information indicating that the client is being manipulative. Acting out is attention-seeking behavior. All clients have a desire to be accepted.

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.

1. The average series involves 6 to 12 treatments.
2. Some confusion may be noted after the procedure.
3. Memory loss will occur but will resolve with time.
4. This treatment is a permanent cure to the condition.
5. This treatment is tried before the use of medications.

1, 2, 3

Rationale:
ECT as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered three times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client’s condition.

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?

1. Biofeedback has the advantage of using no equipment at all.
2. Guided imagery is a helpful technique but requires video equipment for its use.
3. Confrontation is a useful method for solving potentially stressful conflicts with others.
4. Progressive muscle relaxation techniques are useful for easing tension from many causes.

4. Progressive muscle relaxation techniques are useful for easing tension from many causes.

Rationale:
Biofeedback, guided imagery, progressive muscle relaxation, and meditation are techniques that the nurse can teach the client to reduce the physical impact of stress on the body and promote a feeling of self-control. Biofeedback uses electronic equipment, whereas each of the other techniques requires no equipment after it is learned. Confrontation is not a stress management technique; it is a communication technique.

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