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A nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which of the
following activities would be most appropriate initially for this client?
Writing
Solitary activities that require a short attention span with mild physical exertion are the most
appropriate activities initially for a client who is aggressive.
A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse makes which
therapeutic response to the client?
"Tell me about your difficulty sleeping."
The best rationale for using group therapy as an accepted way of treatment of clients in the milieu is
because:
Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts
and feelings in a realistic environment.
Group therapy is a method in which faulty perceptions can be corrected and more effective ways can
be developed to help clients relate to each other. Many client problems are the result of interpersonal
concerns, and group therapy is a useful framework that helps address potential solutions in a realistic
environment.
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,A nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that
an informed consent has not been obtained for the procedure. On review of the record, the nurse notes
that the admission was an involuntary hospitalization. Based on this information, the nurse determines
that:
An informed consent needs to be obtained from the client.
Clients who are involuntarily admitted do not lose their right to informed consent.
A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior
therapy approach is used as part of her treatment plan. The nurse understands that the purpose of this
approach is to:
Help the client identify and examine dysfunctional thoughts and beliefs.
Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be
described as which of the following?
Client involvement in goal setting
Milieu therapy provides a safe environment that is adapted to the individual client's needs and
provides greater comfort and freedom of expression than has been experienced in the past by the
client
A nurse is caring for a client who has been treated with long-term antipsychotic medication. As part of
the nursing care plan, the nurse monitors for tardive dyskinesia. In the event that tardive dyskinesia
occurs, the nurse would likely observe:
Abnormal movements and involuntary movements of the mouth, tongue, and face
Tardive dyskinesia is a severe reaction associated with the long-term use of antipsychotic medication.
The clinical manifestations are abnormal movements (dyskinesia) and involuntary movements of the
mouth, tongue, and face.
tardive dyskinesia
Tardive dyskinesia is a disorder that involves involuntary movements. Most commonly, the
movements affect the lower face. Tardive means delayed and dyskinesia means abnormal movement.
A client has been hospitalized and has participated in substance abuse therapy group sessions. On
discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups.
Which statement by the client would best indicate to the nurse that the client has assimilated therapy
session topics and coping response styles and has processed information effectively for self-use?
"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm
excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be
as helpful as you people."
A nurse receives a telephone call from a male client who states that he wants to kill himself and has a
bottle of sleeping pills in front of him. The best nursing action is to:
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,Keep the client talking and signal to another staff member to send help to the client.
In a crisis, the nurse must take an authoritative, active role to promote the client's safety. A bottle of
sleeping pills in front of a client who verbalizes he wants to kill himself is a "crisis." The client's safety
is of prime concern. Keeping the client on the phone and getting help to the client is the best
intervention
A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that
she believes that someone is poisoning the food. The nurse should make which appropriate response to
the client?
"It must be frightening to you. Has something made you feel that your food is poisoned?"
A nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why
don't you just leave me alone?" The nurse makes which therapeutic response to the client?
"I can see that you are upset. I'll be back in a few minutes to see how you are doing."
A nurse is working with an older client who has a diagnosis of depression. To work most effectively with
this client, the nurse recalls that which of the following is accurate regarding depression and the older
client? Select all that apply.
- Depression in an older person is likely to have physical manifestations.
- Some indications of dementia may actually originate as depression.
- Suicide is a frequent cause of death among the older population.
Depression is treatable in an older client. The nurse should be aware of the implications of
depression, such as physical manifestations, the possibility of dementia, and suicide risk.
A client with Alzheimer's disease became very agitated when a group of children came to sing and dance
at a long-term care facility and the resident tried to take one of the children to her room. The nurse
should use which of the following pieces of information when approaching the client about this
behavior?
Individuals with Alzheimer's disease have difficulty tolerating excess stimulation and changes in routine.
Clients with Alzheimer's disease are likely to be intolerant of excess stimulation and changes in
routine.
A nurse is caring for a client with schizophrenia who states, "I decided not to take my medication
because I realize that it really can't help me. Only I can help me." Which of the following nursing
responses would be therapeutic?
"Your health care provider wants you to continue with this medication because it is helping you. Do you
recall needing to be hospitalized because you stopped your medication?"
Noncompliance with antipsychotic medication is one of the chief reasons that clients with
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, schizophrenia have relapses. The nurse teaches the client with schizophrenia to identify the causes of
relapse.
A nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic
stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which of
the following actions by the nurse would be most beneficial?
Share the observation with the client and help the client to recognize feelings.
Sharing observations with clients may help them to recognize and acknowledge their feelings. Moving
to a quiet room or changing the subject will not help the client to recognize behaviors and feelings.
A nurse working in a mental health unit hears that a client has been experiencing "flashbacks." The
nurse interprets that this client is exhibiting a sign of:
Posttraumatic stress disorder (PTSD)
Flashbacks are the classic manifestation of PTSD.
A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress
disorder (PTSD). The nurse plans to do which of the following initially with this client?
Accept the client as a person and make the client feel safe.
The initial action is to make a confused and disoriented client feel safe
During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes
difficulty with maintaining realistic behavior. Which of the following responses by the nurse would be
therapeutic?
"I can see that you are upset about this. Let's talk about this some more."
The correct response acknowledges the client's feelings. The remaining options do not use therapeutic
communication skills
A client with depression reports to the nurse that she has not been sleeping or eating adequately. The
nurse should plan to do which of the following to assist the client in meeting nutritional needs?
Provide small, frequent meals.
A depressed client may eat small amounts of food rather than large amounts that may be
overwhelming to her. If this client becomes overwhelmed, she may respond by withdrawing further.
A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a
medication that can help people like me quit drinking." The nurse understands that this medication is:
Disulfiram (Antabuse)
Disulfiram is a medication used for alcoholism and aids in the maintenance of sobriety. An adverse
reaction occurs if the client drinks while taking this medication.
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