Latest version with 70 Questions & Verified
answers
Meeting separately with his wife and exploring why he came to the hospital -
ANS✔✔--Observing and evaluating his behavior. The client and his needs are the
priority, and assessment is the first step of the nursing process. Writing a plan of care
for the mental health team is done after a thorough assessment is completed. The
nurse must deal with the present, not the past. Although meeting separately with the
wife should be done, it is not the priority.
A 16-year-old high school student who has anorexia nervosa tells the school nurse that
she thinks she is pregnant even though she has had intercourse only once, more than a
year ago. What is the most appropriate inference for the nurse to make about the
student?
Using magical thinking
Submitting to peer pressure
Lying about the last time she had intercourse
Lacking knowledge that anorexia can cause amenorrhea - ANS✔✔--Lacking
knowledge that anorexia can cause amenorrhea. The loss of body fat from anorexia can
cause amenorrhea; the client needs information. No data are available to support the
fact that the client is using magical thinking, which is characterized by the belief that
thinking or wishing something can cause it to occur; in light of the client's diagnosis of
anorexia, this is not the first conclusion. Submitting to peer pressure is not related to this
type of concern. Although the nurse should question the timeline again, the client's
nutritional status should be explored first.
The nurse is caring for a client with Alzheimer disease who exhibits behaviors
associated with hyperorality. To meet the client's need for a safe milieu, what
instructions will the nurse give the staff to monitor the client?
At meals to help prevent choking
For the presence of mouth ulcers
To prevent injury caused by hot foods
, For attempts at eating inedible objects - ANS✔✔--Hyperorality is the compulsive
need to taste and chew inedible objects. Hyperorality is not related to choking, a
tendency to mouth ulcers, or the inability to perceive temperature properly.
What should a nurse who is caring for a hospitalized older client with dementia consider
before planning care?
Physical contact will increase dependency needs.
Routines provide stability for clients with dementia.
Regressive behavior should be interrupted immediately.
Procedures do not have to be explained to clients with dementia. - ANS✔✔--
Routines provide stability for clients with dementia. Rituals and routines in activities of
daily living provide a framework and structure for clients with dementia, adding to their
sense of safety and security. Touch is a universal message that denotes caring; it can
be soothing and will not encourage dependency. Regressive behavior under stress has
a calming effect and should be allowed. Care should be explained to all clients; simple
declarative statements are usually understood.
A nurse is working in the orientation phase of a therapeutic relationship with a client
who has borderline personality disorder. What will be most difficult for the client at this
stage of the relationship?
Controlling anxiety
Terminating the session on time
Accepting the psychiatric diagnosis
Setting mutual goals for the relationship - ANS✔✔--Setting mutual goals for the
relationship. lients with borderline personality disorder frequently demonstrate a pattern
of unstable interpersonal relationships, impulsiveness, affective instability, and frantic
efforts to avoid abandonment; these behaviors usually create great difficulty in
establishing mutual goals. Although the client with a borderline personality disorder may
have difficulty in the areas of controlling anxiety, ending sessions on time, and
accepting the diagnosis, none is the most significant issue.
A client with a borderline personality disorder is admitted to the mental health unit. What
should the nurse do to maintain a therapeutic relationship with the client?
Provide an unstructured environment to promote self-expression.
Be firm, consistent, and understanding and focus on specific target behaviors.
, Use an authoritarian approach, because this type of client needs to learn to conform to
the rules of society.
A client who was recently admitted to the psychiatric unit with the diagnosis of an
obsessive-compulsive disorder engages in a handwashing ritual. When the nurse
interrupts the ritual, the client becomes angry and acts out. What is the most probable
cause for this behavior? - ANS✔✔--The client is feeling overwhelmed in this situation.
The ritual reduces anxiety; when not permitted to complete the ritual, a client with an
obsessive-compulsive disorder will experience increased anxiety, frustration, and anger
and may act out. The client is experiencing anxiety not related to a personality clash,
the nurse's manner, or an aggressive personality.
The nursing staff is discussing the best way to develop a relationship with a new client
who has antisocial personality disorder. What characteristic of clients with antisocial
personality should the nurses consider when planning care? - ANS✔✔--Exhibits lack
of empathy for other. Self-motivation and self-satisfaction are of paramount concern to
people with antisocial personality disorder, and they have little or no concern for others.
Clients with obsessive-compulsive disorder, not antisocial personality disorder, engage
in rituals. Individuals with antisocial personality disorder are extremely dependent on
others; they count on others to extricate them from their problems. They are usually
charming on the surface and can easily con people into doing what they want.
A client remains depressed even after an 8-week trial on several antidepressant
medications. A decision to initiate electroconvulsive therapy (ECT) is being considered
by the treatment team. Which condition is a contraindication to ECT?
Brain tumor
Type 1 diabetes
Hypothyroid disorder
Inappropriate affect - ANS✔✔--Ambivalence is the existence of two conflicting
emotions, impulses, or desires. Double bind is two conflicting messages, not emotions,
in a single communication. Loose associations are not two conflicting emotions but
instead the loosening of connections between thoughts. Inappropriate affect is the
inappropriate expression of emotions.
A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity
disorder who engages in self-destructive behavior. What is the most important nursing
objective in the planning of care for this child?