Question 1

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an intervention?

Accepted Answer

Symptoms of ADHD usually continue into adulthood; current research indicates that children do not outgrow the condition. However, individuals with ADHD learn to cope with and manage the symptoms and achieve their full potential, leading healthy and satisfying lives. They may move into a condition of being "recovered," but this is usually a dynamic and ongoing state. (Option A) Children with ADHD are usually overwhelmed and overstimulated when faced with numerous choices. Offering 2 choices will help organize and structure the child's decision-making process. (Option B) There are legal mandates requiring school-based services and accommodations for children with ADHD. However, some teachers and/or school systems may not be as familiar with these requirements; it is important that parents of children with ADHD advocate for these individualized services. (Option D) Parents and caregivers should make direct eye contact and focus on their children when giving instructions. Other distractions should be minimized to avoid overstimulation. Educational objective: Two common misunderstandings about ADHD are that children outgrow it as they become adults, and that dietary modifications (eg, restricting additives and/or sugar) will improve or "cure" the symptoms. Neither statement is true. These individuals learn to cope with and manage their symptoms as they grow older, but they do not outgrow ADHD.

Question 2

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply.

Accepted Answer

Bulimia nervosa is an eating disorder common among adolescent girls and characterized by cycles of uncontrollable overeating (binging) followed by compensating behaviors to avoid weight gain (purging). Weight-maintenance behaviors include self-induced vomiting, fasting, laxative abuse, and excessive exercise. Clients may be of normal weight, which contributes to the hidden nature of this disorder. Clients with bulimia often experience extreme guilt associated with their increasing lack of control and attempt to hide evidence of their actions (eg, hidden food wrappers from binging, discarded food from unfinished meals). Clients should be monitored around meal times, and particularly for 1-2 hours after eating to observe for purging. Purging behaviors, particularly vomiting, may result in electrolyte imbalances, such as hypokalemia, that can cause cardiac arrhythmias. (Option A) Clients with bulimia nervosa often use laxatives inappropriately to rid their bodies of undigested food in an effort to control their weight. Such measures should not continue in the treatment setting. (Option D) A food diary helps the client and caregivers track the type and amount of food that the client has eaten. It is also an excellent means of helping the client understand the health implications of the disorder. Educational objective: Clients with bulimia nervosa should be monitored for signs of hidden binging or purging activity, particularly for 1-2 hours after meals. Excessive vomiting may result in electrolyte imbalances, including hypokalemia.

Question 3

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? Select all that apply.

Accepted Answer

Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to understand them and the nurse-client relationship grows (Option C). Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions (Option B). For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real." (Option A) Attempting to explore the meaning behind a delusion will encourage the client to focus/think more on this delusion. (Option D) Confronting the client about the delusion is not therapeutic because arguing will not eradicate the delusion. It also hinders the development of a trusting nurse-client relationship. (Option E) Clients believe that their delusions are real despite proof otherwise. Presenting logical explanations to discredit the delusions will not help. Educational objective: When communicating with a delusional client, the nurse must focus on the client's feelings and reinforce reality rather than argue or present evidence that the delusion is false or irrational.

Question 4

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference.  Which client statement supports this symptom?

Accepted Answer

Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs, newspaper articles, and other events are personal and significant to them. Other examples of delusions are below: Grandeur - "I need to get to Washington for my meeting with the president." Control - "Don't drink the tap water. That's how the government controls us." Nihilistic - "It doesn't matter if I take my medicine. I'm already dead." Somatic - "The doctor said I'm fine, but I really have lung cancer." (Option A) This client statement is an example of a tactile hallucination, which gives the client the sensation of being touched. (Option B) This client statement is an example of an auditory hallucination, specifically a command hallucination. Clients experiencing auditory hallucinations hear sounds and voices others do not. (Option D) This client statement is an example of a persecutory (paranoid) delusion. Clients with such delusions believe that they are being threatened or treated unfairly in some way. Educational objective: Delusions are a positive symptom of schizophrenia. Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them.

Question 5

A client with social anxiety disorder is receiving treatment at the local community mental health center.  Which situation most likely caused the client to seek therapy?

Accepted Answer

Social anxiety disorder (SAD) is characterized by an excessive and persistent fear of social or performance situations in which the client is exposed to strangers and the possibility of scrutiny by others. Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public, and giving a speech. The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and blushing. Although all these situations could provoke some degree of anxiety in a client with SAD, having to represent the company at a convention with hundreds of strangers is most likely what brought this client to the community mental health center. Clients with SAD often have anticipatory anxiety and worry for days or weeks before a feared event. They may recognize that their fear is exaggerated and will seek assistance and counseling. (Option A) The prospect of a new neighborhood may cause the client some anxiety; however, in this situation, the client has some control over exposure to new neighbors. The client can control this fear by limiting encounters or avoiding the neighbors altogether. (Option C) Seeing a new HCP may cause some degree of discomfort in a client with SAD; however, as a one-on-one encounter, it is not like to cause severe anxiety or panic. (Option D) In this situation, the client will be around familiar and possibly unfamiliar people. If necessary, the client can create a comfort zone by limiting contact with unfamiliar people. Educational objective: Clients with social anxiety disorder have an excessive, persistent fear of social or performance situations involving strangers and the possibility of criticism, embarrassment, humiliation, and rejection. The fear of the situation(s) causes severe anxiety and avoidance.

Question 6

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing."  Which summary is true regarding the nurse's response?

Accepted Answer

The nurse has used a nontherapeutic communication technique known as "giving reassurance" or "giving false reassurance." A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. This technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued. (Option A) The nurse has not encouraged exploration of this client's feelings and options. This could have been done by using any one of several therapeutic communication techniques (eg, reflecting, focusing, exploring). An appropriate response by the nurse, such as stating, "Tell me what concerns you have," would have facilitated communication with the client. therapeutic communication (Option B) The nurse has shown no interest in the client's concerns; instead, the nurse should show interest, be available, and have a conversation with the client (eg, "I will stay and listen to your concerns"). (Option C) The nurse has not conveyed empathy (attempting to understand and share the feelings behind a client's actions and words). An empathetic nurse might say, "This must be hard for you," or, "I understand you are upset." Educational objective: The nurse must learn to use effective therapeutic communication skills to enhance the development of a trusting and therapeutic nurse-client relationship.

Question 7

A nurse is admitting a child and observes multiple irregular bruises. Which action should the nurse take next?

Accepted Answer

A nurse who suspects child abuse should conduct a detailed interview and physical examination to identify potential indicators of abuse (Option B). In addition to obvious injuries, abused children may show extremes in behavior, including being overly shy, fearful, or even unusually affectionate. Parents should remain present during the admission process and the nurse should observe parent-child interactions for signs of abusive behavior (eg, refusal to comfort, blaming, belittling) (Option A). Abusive parents may be hostile or uncooperative with the health care team. The nurse should also assess for inconsistencies between the parents' report and the actual findings. (Option C) The nurse should report findings that indicate abuse to the charge nurse, social worker, and health care provider only after conducting a full history and physical examination. (Option D) The nurse should not make promises of secrecy to the child or family if abuse is revealed. The child or family should be told that the nurse is required by law to report all abuse. Educational objective: If child abuse is suspected, the nurse should obtain a detailed history, perform a physical examination, and report signs of abuse. Parent-child interaction should be examined closely, and any inconsistencies between a parent's report and the actual findings should be documented.

Question 8

After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the best response by the nurse?

Accepted Answer

A nursing diagnosis associated with anorexia nervosa is disturbed body image/low self esteem. There is often a large disparity between actual weight and the client's perceived weight. Clients with anorexia nervosa think of themselves as overweight and fat. The nursing care plan should include helping the client develop a realistic perception of weight and body image. The nurse can confront the client about the misinterpretation of body weight by presenting reality without challenging the client's illogical thinking. The client's weight should be discussed in the context of overall health. The nurse also needs to be aware of his/her own reaction to the client's behaviors and statement. It is not uncommon for caregivers and care providers to feel frustrated or even angry when caring for a client with an eating disorder. The nurse must maintain a neutral attitude and approach, avoiding arguing or disagreeing with the client's statements. (Option A) This response is judgmental, reinforces the idea of "thinness," and does not help the client develop a more realistic body image. (Option C) Establishing a goal weight is part of the nursing care plan for the client with anorexia nervosa; clients are usually not discharged from inpatient treatment until goal weight is achieved. However, this response does not address the client's misperception of body weight. (Option D) This response dismisses the client's concern and does not present the reality of the situation. Educational objective: Clients with anorexia nervosa have disturbed body image and see themselves as being fat or overweight even when they are severely underweight or even at a normal body weight. The nurse can help the client develop a more realistic self image by presenting the situation realistically and discussing weight in terms of the client's health.

Question 9

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply.

Accepted Answer

Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking. These types of disorders are characterized by maladaptive reactions to stress, anxiety, and conflict. CBT requires that the client learn the skill of self-observation and to apply more adaptive coping interventions. CBT involves 5 basic components: Education about the client's specific disorder Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity Physical control strategies - deep breathing and muscle relaxation exercises Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative thoughts Behavioral strategies - focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events (Option B) This describes interpersonal psychotherapy. (Option C) This describes psychodynamic or psychoanalytic therapy. Educational objective: CBT teaches clients to reframe their thought processes and develop new adaptive approaches for coping with anxiety, stress, and conflict. CBT requires that the client learn about the disorder and engage in self-observation and monitoring, relaxation techniques, desensitization activities, and changing negative thoughts.

Question 10

The nurse cares for a client who just had surgical excision and biopsy of a tumor.  The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider.  The client asks the nurse, "Am I going to die?"  Which statement by the nurse is appropriate?

Accepted Answer

Clients with life-limiting diagnoses often experience anxiety, frustration, and the phases of grief. The nurse must assess the client's knowledge and feelings regarding the illness. Use of therapeutic communication (eg, active listening, reflection, focusing) allows the nurse to determine client needs and strengthens the nurse-client relationship, which is instrumental in helping the client cope with difficult information (Option B). The health care provider (HCP) should inform the client of biopsy results so that the prognosis and plan of treatment can be discussed. Although a cancer diagnosis may be difficult for the client to receive, a complete, factual discussion of the diagnosis can help the client feel more in control. (Option A) Indicating knowledge of the client's feelings and changing the subject weaken the nurse-client relationship by making the nurse seem uncomfortable with the situation, minimizing the client's feelings, and disregarding client concerns. (Option C) The HCP should be involved in informing the client about the biopsy results. It is best that both the HCP and nurse be present to address all questions and concerns the client may have. (Option D) An automatic response is a nontherapeutic communication technique that deflects the client's feelings, thereby weakening the nurse-client relationship. The nurse should encourage the client to share their thoughts. Educational objective: Clients with life-limiting diagnoses experience anxiety, frustration, and grief as they cope. The nurse should use therapeutic communication (eg, active listening, reflection, focusing) to determine the client's understanding and strengthen the nurse-client relationship before discussing difficult news (eg, new cancer diagnosis).

Question 11

A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. The client can state the name and address but has no recollection of the past 2 days. What is the priority nursing action?

Accepted Answer

This client is experiencing amnesia of undetermined origin. The cause could stem from a medical condition, substance abuse, traumatic brain injury, cognitive disorder such as dementia, or psychiatric condition such as dissociative fugue. Regardless of the diagnosis, the priority nursing action is to assess the client's physical status. This client has been wandering for 2 days and cannot recall previous locations, arriving at the present location, and the timetable involved. It is highly probable that the client is dehydrated and fatigued. It is most important to assess the client's physical needs and implement interventions to stabilize the physiologic condition before assessing psychosocial status and needs. (Option B) It is appropriate to contact this client's family members. However, this is not the priority nursing action. (Option C) This client may never be able to remember the events of the past 2 days. Encouraging a client to remember something when there is no sign of recollection may only increase client frustration. (Option D) A mental status examination is an important component of the nurse's assessment. However, it is not the priority assessment. Educational objective: Assessment of a client's physiologic status and needs is the priority nursing action when the client is suffering from amnesia with no recollection of where he has been or what he has been doing for a period of time. Interventions need to be implemented to stabilize the client physically before psychosocial needs are addressed.

Question 12

A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide. The client now reports feeling "emotionally upset, alone, and at the end of my rope," due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP). What is the priority nursing diagnosis (ND) at this time?

Accepted Answer

Suicide is the second leading cause of death in people age 15-24. The risk for suicide is increased in individuals with psychiatric disorders, such as depression, and in those who have attempted suicide within the past 2 years. Based on the client's history and statements, the HCP must perform a suicide assessment and take action (ie, psychiatry referral) to provide for the client's safety. This is imperative as the client is prescribed the antidepressant fluoxetine (Prozac) and has had no follow-up with the prescribing HCP. Risk for suicide related to depression is the priority ND. (Option A) Hopelessness is the belief that a situation or problem is intolerable, inescapable, or unending, and the individual is unable to find a solution. Hopelessness related to inability to find a job, social isolation, lack of medical insurance, and feeling at the "end of my rope" is an appropriate ND for this client, but it is not the priority ND at this time. (Option B) Ineffective coping is the inability to manage stressors and problems effectively. Depression can affect a client's cognitive ability (eg, poor concentration, lack of judgment) and ability to cope with feelings of despair. Ineffective coping related to inadequate support network, limited socioeconomic resources, and impaired cognitive ability is an appropriate ND for this client, but it is not the priority ND at this time. (Option C) Risk for infection related to inadequate primary defenses secondary to impaired skin integrity is an appropriate ND for this client, but it is not the priority ND at this time. Educational objective: Risk for suicide related to depression is a priority ND for a client with previous suicide attempts.

Question 13

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action?

Accepted Answer

This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support. Additional nursing actions while the client is experiencing panic symptoms include: Maintaining a calm, matter-of-fact approach Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures Placing the client in a room with as few stimuli as possible Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription) Having the client take slow, deep breaths if hyperventilation is a problem (Option A) Deep breathing exercises can relieve hyperventilation, but the priority is to remain with the client to ensure safety. (Option B) Discussing the reasons for the panic attack is not appropriate while the client is still symptomatic. Once the client has calmed down, the nurse can discuss reasons for the attacks, evaluate stressors in the client's life, and assist the client in developing prevention strategies. (Option C) A private room is appropriate; however, just telling a client to relax is not helpful. Educational objective: The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment, ensure the client's safety, and offer support.

Question 14

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is most consistent with the diagnosis of delirium?

Accepted Answer

The Confusion Assessment Method (CAM) is used to determine delirium. The signs are acute mental status changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and pain. Delirium has an abrupt onset and is a symptom of other problems. Up to 60% of hospitalized elderly clients have delirium prior to or during hospitalization, but it is often missed by nursing. (Option A) This can be due to dementia or just an acute mental status change. Further assessment would be necessary. However, fluctuating mental status changes and inattention that are characteristic of delirium are not present in this client. (Option C) This is a sign of depression. Two simple screening questions for depression include the following: "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" "During the past month, have you often felt minimal interest or pleasure in doing things you used to enjoy?" (Option D) This describes dementia. Its onset is slow and insidious, and family members usually notice it first. The client's attention level is usually normal. Educational objective: Delirium has a sudden onset and involves fluctuating mental status and inattention with disorganized thinking and/or altered level of consciousness. Dementia has a slow onset, usually with normal attention. Depression involves loss of interest in previously pleasurable activities.

Question 15

The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides. Which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse? Select all that apply.

Accepted Answer

Typical characteristics of child abuse perpetrators include: Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child Confusion between punishment and discipline; having a stern, authoritative approach to discipline Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation (Option A) Low self-esteem-a sense of incompetence or unworthiness as a parent (Option D) A history of substance abuse; use of alcohol or drugs at the time the abuse occurs (Option B) Punitive treatment and/or abuse as a child Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age (Option E) Resentment or rejection of the child Low tolerance for frustration and poor impulse control Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury (Option C) Child abusers are not easily identified by appearance; they often appear calm and well in control but may have violent outbursts, typically in private. Educational objective: Child abusers often have a history of growing up in an environment of domestic violence and have a sense of low self-esteem. History of substance abuse is also a risk factor. Teenage parents are particularly vulnerable to abusing their children.

Question 16

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply.

Accepted Answer

Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. (Option C) Anorexia nervosa manifests as cold intolerance. (Option E) Anorexia nervosa manifests as lengthy and vigorous exercise. Educational objective: The clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea, bradycardia, cold intolerance, dry skin, and lanugo. Life-threatening complications, such as cardiac arrhythmias associated with hypokalemia, may develop.

Question 17

A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse; I know you'll be a good sport and give me a pass." What is the best response by the nurse?

Accepted Answer

Manipulative behaviors, such as attempts at staff splitting, are common in clients with borderline and antisocial personality disorders, substance abuse problems, somatic symptom disorder, and bipolar disorder (during the manic phase). The manipulative behavior is aimed at gaining control/power over a person/situation or for material gratification. Clients manipulate by flattery or by pitting staff members against each other. They may "tell" on a staff member or act in a way to give the impression of sincerity and caring. Nursing interventions for manipulative behaviors include: Setting limits that are realistic, nonpunitive, and enforceable Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors Enforcing all unit, hospital, or center rules (Option D) Ensuring consistency from all staff members in enforcing set limits (Option A) Telling the client the gift shop is closed does not address the client's manipulative behavior. (Option B) Believing the client's statement is not appropriate as it will only reinforce the client's manipulative behavior. (Option C) Asking the client the reason for going to the gift shop ignores the fact that the client is trying to break the rules. Educational objective: Clients who want to gain power or control over a situation or desire material gratification may use manipulative behaviors (eg, staff splitting). Nursing interventions include setting behavioral limits; using a neutral, matter-of-fact tone when discussing rules and consequences of unacceptable behavior; and ensuring consistency from staff members in enforcing limits.

Question 18

The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take?

Accepted Answer

Any client who cannot definitively say that currently he/she is not suicidal should be considered a "yes" and appropriate protective measures should be instituted to prevent suicidal actions. The client is under the hospital's care and the department must assume responsibility for the client's safety. Placing the client in an inside hallway can prevent the client from running outside. The client needs constant supervision by a hospital employee until a secure room is available. The client should never be left alone without hospital supervision. (Option A) A verbal contract is a viable option but might not be accomplished appropriately in the triage area. Also, its efficacy is questionable. Emergency department triage should be accomplished in 3-5 minutes. In addition, the triage nurse may not have the skills to adequately perform this intervention. Safety should always be the first priority, and precautions should be taken until the client is determined to not be suicidal. (Option B) Any ambivalence, especially given the client's previous actions and statements, should be considered a "yes." (Option D) It is unfair to expect the spouse to perform the same level of care as a health care provider; the spouse brought the client to the hospital for additional help. It would be appropriate to have the spouse present with the client in a secure setting. The spouse would also be instructed to keep the client in sight at all times. Having the client and spouse return to the waiting room would provide the opportunity for the client to bolt from the hospital. Educational objective: Any client who expresses ambivalence about being suicidal should be treated as a "yes." The client must be in a safe environment with hospital supervision and should not be left alone.

Question 19

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the bestresponse by the nurse?

Accepted Answer

This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident"). When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion. Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness. Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at alleviating the immediate emotional impact of this disruptive crisis event. Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress. (Option A) Assessing this family's support system is important. However, it is not the priority action at this time. (Option B) This statement does not address what this client's spouse is experiencing at the moment. At a later time, the nurse can explore the client's history and any events that may have lead to this situation. (Option D) This response does not address the spouse's concerns. Also, the wording is judgmental and nontherapeutic. Educational objective: Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, and confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions.

Question 20

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder?

Accepted Answer

Individuals with agoraphobia have fear and anxiety about being in (or anticipating) certain situations or physical spaces. The fear they experience is out of proportion to any actual danger. These individuals are also highly concerned about having trouble escaping or getting help in the event of a panic attack or panic symptoms. The primary psychological need in agoraphobia is to avoid panic, and individuals with this condition will engage in various behaviors to lessen anxiety and avoid specific situations. In severe agoraphobia, the individual may become homebound, not going to public places for fear of experiencing a panic attack that may cause them to become embarrassed or perform an uncontrollable act. The person with agoraphobia will often feel the need to be accompanied by a relative or friend when facing situations. Agoraphobic individuals most typically fear being in the following situations: Outside the home alone In a crowd or standing in line Traveling in a bus, train, car, ship, or airplane On a bridge or in a tunnel Open spaces (eg, parking lots, marketplaces) Enclosed spaces (eg, theaters, concert halls, stores) (Option B) In generalized anxiety disorder, the anxiety is evident in various situations and can impact all areas of an individual's life (eg, workplace, family/relationships, general well-being). (Option C) In social anxiety disorder, individuals fear being scrutinized, observed, or embarrassed in social or performance settings (eg, public speaking, eating in public). (Option D) Zoophobia is fear of animals. Educational objective: Agoraphobia is characterized by intense anxiety about being in a situation from which there may be difficulty escaping in the event of a panic attack. A person with agoraphobia may avoid open spaces, closed spaces, riding in public or private transportation, going outside the home, bridges/tunnels, and crowds.

Exam 7: Mental Health

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD) , combined type. Which statement by the parent requires an intervention?

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply.

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? Select all that apply.

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom?

A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy?

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response?

A nurse is admitting a child and observes multiple irregular bruises. Which action should the nurse take next?

After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the best response by the nurse?

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT) . The CBT includes which interventions and strategies? Select all that apply.

The nurse cares for a client who just had surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "Am I going to die?" Which statement by the nurse is appropriate?

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action?

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is most consistent with the diagnosis of delirium?

The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides. Which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse? Select all that apply.

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply.

A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse; I know you'll be a good sport and give me a pass." What is the best response by the nurse?

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder?