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Despite repeated nursing interventions to improve reality orientation, a client
insists that he is the commander of an alien spaceship. What is the client
experiencing? - ANSWER ✓ Delusion
A client with dementia has been cared for by the spouse for 5 years. During the
last month the client has become agitated and aggressive and is incontinent of urine
and feces. What is the priority nursing care while this client is in an inpatient
mental health facility? - ANSWER ✓ Managing the behavior
A constructive but lengthy method of confronting the stress of adolescence and
preventing a negative and unhealthy developmental outcome is: - ANSWER ✓
Role experimentation
A client with phobias about elevators and large crowds comes to the clinic for help
because of feelings of depression related to these fears. What is an appropriate
short-term goal for this client? - ANSWER ✓ Describing the thoughts and feelings
experienced in terrifying situations
What defense mechanism should the nurse anticipate that a client with the
diagnosis of schizophrenia, undifferentiated type, will most often exhibit? -
ANSWER ✓ Regression
A nurse knows that children with attention deficit-hyperactivity disorder (ADHD)
may be learning disabled. This means that these children: - ANSWER ✓
Experience perceptual difficulties that interfere with learning
A nurse is caring for a group of depressed clients. What should the nurse attempt
to provide? - ANSWER ✓ An uncomplicated daily schedule
, A nurse is working with an adolescent client with conduct disorder. Which
strategies should the nurse implement while working on the goal of increasing the
client's ability to meet personal needs without manipulating others? (Select all that
apply.) - ANSWER ✓ Provide physical outlets for aggressive feelings
Establish a contract regarding manipulative behavior
Develop activities that provide opportunities for success
A client is using ritualistic behaviors. Why should a nurse give the client ample
time in which to perform the ritual? - ANSWER ✓ Denial of this activity may
precipitate a panic level of anxiety.
A client with a history of sleeplessness, lack of interest in eating, and excessive
purchases on charge accounts is seen in the mental health clinic. The adaptation
that the nurse should expect the client to exhibit is: - ANSWER ✓ Intrusive
involvement with environmental activities
A young client is admitted to the hospital with a diagnosis of acute schizophrenia.
The family reports that one day the client looked at a linen sheet on a clothesline
and thought it was a ghost. What is the most appropriate conclusion to make about
what the client was experiencing? - ANSWER ✓ Illusion
A college student visits the health center and describes anxiety about having to
declare an academic major. What developmental conflict, according to Erikson, is
this client still attempting to resolve? - ANSWER ✓ Identity versus role confusion
As a nurse enters a room and approaches a client who has schizophrenia, the client
shouts, "Get out of here before I hit you! Go away!" The nurse concludes that this
aggressive behavior is probably related to the fact that the client felt: - ANSWER
✓ Confined when the nurse walked into the room
A man with bipolar disorder, manic episode, has been traveling around the
country, dating multiple women, and buying his dates expensive gifts. He is
admitted to the hospital when he becomes exhausted and runs out of money. The
nurse anticipates that during a manic episode the client is most likely experiencing
feelings of: - ANSWER ✓ Grandeur
,How should a nurse expect a client's anxiety to be manifested physiologically? -
ANSWER ✓ Increased blood glucose level
What is the prognosis for a normal productive life for a child with autism? -
ANSWER ✓ Unlikely because of interference with so many parameters of
function
The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day
for a client exhibiting initial signs of dementia of the Alzheimer type. The client is
already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax)
0.5 mg twice a day. What should the nurse teach the client's spouse to do? -
ANSWER ✓ Prefill a weekly drug box with the medications for the spouse to self-
administer
A hospitalized, depressed, suicidal client has been taking a mood-elevating
medication for several weeks. The client's energy is returning and the client no
longer talks about suicide. What should the nurse do in response to this client's
behavior? - ANSWER ✓ Keep the client under closer observation
A client in the outpatient clinic is denying that he is addicted to alcohol. He tells
the nurse that he is not an alcoholic and that it is his nagging wife who causes him
to drink. What is the most therapeutic response by the nurse? - ANSWER ✓
"Everyone is responsible for his own actions."
A depressed client tells a nurse, "I want to die." What is the most therapeutic
response by the nurse? - ANSWER ✓ "You would rather not live."
An adolescent with a conduct disorder is undergoing behavioral therapy in an
attempt to limit behaviors that violate societal norms. A specific outcome criterion
unique to adolescents with this problem is: - ANSWER ✓ Demonstration of
respect for the rights of others
A client tells a nurse, "I have been having trouble sleeping and feel wide awake as
soon as I get into bed." Which strategies should the nurse teach the client that will
promote sleep? (Select all that apply.) - ANSWER ✓ Leaving the bedroom when
unable to sleep
Exercising in the afternoon rather than in the evening
Counting backward from 100 to 0 when his mind is racing
, A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" The
nurse determines that the client is exhibiting: - ANSWER ✓ Neologism
What is important when the nurse plans care for a client with paranoid ideation? -
ANSWER ✓ Providing the client with opportunities for nonthreatening social
interaction
A client who is in a manic phase of bipolar disorder threatens staff and clients on a
psychiatric acute care unit. Place the following interventions in priority order, from
the least to the most restrictive. - ANSWER ✓ Diversional activities
Limit-setting
Medication administration
Seclusion
Restraints
During the orientation tour for three new staff members, a young, hyperactive
manic client greets them by saying, "Welcome to the funny farm. I'm Jo-Jo, the
head yo-yo." Which meaning can the nurse assign to the client's statement? -
ANSWER ✓ Anxious over the arrival of new staff members
When a nurse sits next to a depressed client and begins to talk, the client responds,
"I'm stupid and useless. Talk with the other people who are more important."
Which response is most therapeutic? - ANSWER ✓ Imitating and participating in
the child's activities
People who are involved in a bioterrorism attack exhibit immediate reactions to
the traumatic event. Which responses can a nurse expect in survivors during the
period immediately following a traumatic event? (Select all that apply.) -
ANSWER ✓ Denial
Confusion
Helplessness
A client newly admitted to the psychiatric unit because of an acute psychotic
episode is actively hallucinating. The admitting nurse has documented the content
of the auditory hallucinations, which center on the theme of powerlessness. Later
the primary nurse approaches the client, who appears to be listening to voices, and
comments, "You seem to be listening to something. Tell me what you hear." The
primary nurse requests feedback from the psychiatric clinical specialist regarding