.A client is fearful of driving and enters a behavioral therapy program tohelp him overcome his anxiety. Using systematic desensitization, he is ableto
... [Show More] drive down a familiar street without experiencing a panic attack. Thenurse should recognize that to continue positive results, the client should participate in which of the following?
a. Biofeedback
b. Therapist modeling
c. Frequent pacing
d. Positive reinforcement
a. Biofeedback
A nurse is counseling a client following the death of the client's partner 8months ago. Which of the following client statements indicates maladaptive grieving?
a. "I am so sorry for the times I was angry with my partner."
b. "I like looking at his personal items in the closet."
c. "I find myself thinking about my partner often."
d. "I still don't feel up to returning to work.
d. I still don't feel up to returning to work.
A nurse in an inpatient mental health facility is assessing a client who
has schizophrenia and is taking haloperidol (anti-psychotic, 1st gen).
Which of the following clinical findings is the nurse's priority?
a. Headache
b. Insomnia
c. Urinary hesitancy
d. High fever
d. high fever
A nurse is planning care for a client who has obsessive compulsive
disorder. Which of the following recommendations should the nurse include in the client's plan of care?
a. Reality Orientation therapy
b. Operant Conditioning
c. Thought Stopping
d. Validation Therapy
c. thought stopping
A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the teaching?
a. "I will provide my mother with detailed instructions about how to perform self-care."
b. "I will limit my mother's clothing choices when she is getting
dressed."
c. "I will wake my mother up a couple of times in the night to check on her."
d. "I will discourage my mother from talking about her physical complaints."
b. "I will limit my mother's clothing choices when she is getting dressed."
A nurse is caring for a client who is in the manic phase of bipolar
disorder. Which of the following actions should the nurse take?
a. Provide in depth explanation of nursing expectations
b. Encourage the client to participate in group activities
c. Avoid power struggles by remaining neutral
d. Allow the client to set limits for his behavior
c. Avoid power struggles by remaining neutral
A nurse is providing behavioral therapy for a client who has OCD. The
client repeatedly checks that the doors are locked at night. Which of the
following instructions should the nurse give the client when using thought
stopping technique?
a. "Keep a journal of how often you check the locks each night."
b. "Ask a family member to check the locks for you at night."
c. "Focus on abdominal breathing whenever you go to check the
locks."
d. "Snap a rubber band on your wrist when you think about
checking the locks."
d. "Snap a rubber band on your wrist when you think about
checking the locks."
A nurse is caring for a client who has a cocaine use disorder. Which of
the following manifestations should the nurse expect the client to have
during withdrawal?
a. Hand tremors (Intoxication)
b. Fatigue
c. Seizures (Intoxication)
d. Rapid speech
b. fatigue
A nurse is reviewing the medical record of a client who is taking
clozapine. For which of the following findings should the nurse withhold the
medication and notify the provider?
a. WBC count
b. Heart rate
c. Report of photosensitivity
d. Blood glucose level
a. wbc count
A nurse is creating a plan of care for a client who has major
depressive disorder. Which of the following interventions should the
nurse include in the plan?
a. Keep the ring light on in the client's room at night
b. Encourage physical activity for the client during the day
c. Identity and schedule alternative group activities for the client
d. Discourage the client from expressing feeling of anger
b. Encourage physical activity for the client during the day
A nurse is assessing a client who is experiencing acute alcohol
withdrawal. Which of the following findings should the nurse expect?
a. Diminished reflexes
b. Hypotension - increased BP
c. Insomnia
d. Bradycardia
c. insomnia
A nurse is caring for a client who has schizophrenia and displays
severe symptoms of the disorder. Which of the following actions should the
nurse take?
a. Use medication to decrease frequency of auditory and visual
hallucinations
b. Assist the client to identify somatic and thought broadcast delusion
(Identify symptom triggers, such as loud noises (can trigger auditory hallucinations in certain clients)
and situations that seem to trigger conversations about the client's delusions.
c. Manage the client's loud, rambling, and incoherent communication
patterns
d. Direct the client to perform her own daily hygiene and
grooming tasks
d. Direct the client to perform her own daily hygiene and
grooming tasks
A nurse is caring for a client who was involuntarily committed and is
scheduled to receive electroconvulsive therapy. The client refuses the
treatment and will discuss why with the healthcare team. Which of the
following actions should the nurse take?
a. Document the client's refusal of the treatment in the
medication record
b. Tell the client he cannot refuse the treatment because he was
involuntarily committed
c. Inform the client the ECT does not require client consent
d. Ask the client family to encourage the client to receive ECT
a. Document the client's refusal of the treatment in the
medication record
A nurse is providing crisis intervention for a client who was involved in a
violent mass casualty situation in the community. Which of the following
actions should the nurse take during the initial session with the client?
a. Identify the client's usual coping style.
b. Encourage the client to display anger toward the cause of the crisis.
(Reduce stress-related manifestations, such as using techniques to alleviate a panic attack)
c. Tell the client that this life will soon return to normal (False assurance)
d. Help the client focus on a wide variety of topics regarding the crisis.
a. identify the client's usual coping style
A nurse in the emergency department is caring for a client who reports
feeling sad, worthless, and hopeless 9 months after the death of her son.
Which of the following actions should the nurse take first?
a. Encourage the client to attend a grief support group
b. Discuss the client's coping skills
c. Request a mental health consult for the client
d. Ask the client if she has thought about harming herself
d. Ask the client if she has thought about harming herself
A nurse is planning care for an adolescent who has autism spectrum
disorder. Which of the following outcomes should the nurse include in the
plan of care?
a. Acknowledges that his delusions are not real
b. Changes behavior as a result of peer pressure
c. Initiate social interactions with caregiver
d. Meets own needs without manipulating others.
c. Initiate social interactions with caregiver
A nurse is caring for a client who is experiencing active auditory
hallucination. Which of the following should the nurse take?
a. Avoid asking direct questions about the client's experience
b. Tell the client her experience is not real
c. Convey sympathy for her client's experience
d. Focus the client on reality based activities
d. Focus the client on reality based activities
A nurse is conducting an admission interview with a client who is
experiencing mania. Which of the following findings the nurse reports to the
provider?
a. Reports eating twice in the past week
b. States that he hasn't bathed in 2 days
c. Speaks in rhyming sentences
d. Makes inappropriate sexual comments
a. Reports eating twice in the past week
A nurse is caring for a client who has anorexia nervosa. Which of the
following findings requires immediate intervention by the nurse?
a. Lanugo covering the body
b. Blood pH 7.40
c. +2 edema of the lower extremities
d. BUN 21 mg/dL
+2 edema of the lower extremities
A nurse is planning care for a client who has a recent diagnosis of
antisocial personality disorder. Which of the following outcomes should
the nurse in the care plan?
a. The client treats others with respect
b. The client recognizes the importance of others
c. The client reduces self-dramatization
d. The client conforms to social norms regarding clothing choices
a. The client treats others with respect
A nurse is caring for a client who is prescribed massage therapy to treat
panic disorder. The client states "I can't stand to be touched by another
person". Which of the following response should the nurse make?
a. Why don't you like to be touched by others?
b. I will request that the massage therapist wear gloves during your
treatment
c. I will tell your provider know that you would like a treat other
than a message
d. Don't worry about it. Your anxiety will lessen once the massage begins
c. I will tell your provider know that you would like a treat other
than a message
A nurse in a group home facility is caring for a client who is
developmentally disabled. The client has been stealing belongings from
the other clients. Which of the following techniques should the nurse use?
a. Crisis intervention to decrease anxiety
b. Aversion therapy to provide distraction
c. Systematic desensitization to extinguish the behavior
d. Positive reinforcement to increase desired behavior
b. Aversion therapy to provide distraction [Show Less]