A nurse is planning overall strategies to address problems for a client who
has a borderline personality disorder. Which of the following strategies is
... [Show More] the
priority for the nurse to incorporate into the plan of care?
a. discuss the appropriate use of assertive behavior with the client
b. encourage the client to attend weekly support group meetings
c. assist the client to maintain awareness of her thoughts and feelings
d. implement measures to prevent intentional self-inflicted injury - d. implement measures to prevent intentional self-inflicted injury
A nurse is admitting a client who has a generalized anxiety disorder. Which of the following actions should the nurse plan to take first?
a. Provide the client with a quiet environment
b. Determine how the client handles stress.
c. Teach the client to use guided imagery.
d. Ask the client to identify her strengths - a. Provide the client with a quiet environment
A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following should the nurse report to the provider?
a. States that he hasn't bathed in 2 days
b. Reports eating twice in the past two weeks.
c. Makes inappropriate sexual comments.
d. Speaks in rhyming sentences. - b. Reports eating twice in the past two weeks.
A nurse is planning care for a client who has obsessive-compulsive disorder. Which of the following recommendation should the nurse include in the client's plan of care?
a. Validation therapy
b. Thought stopping
c. Operant conditioning
d. Reality orientation therapy - b. Thought stopping
A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
a. Encourage the client to join group activities
b. Dim the lights in the client's room
c. Provide detailed explanations to the client
d. Administer methylphenidate - b. Dim the lights in the client's room
A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?
a. Initiate referrals
b. Review community resources
c. Identify prior coping skills
d. Discuss the importance of confidentiality - c. Identify prior coping skills
A nurse overhears a client saying"I am a spy, a spy for the FBI .I am an I,an eye for an eye in the sky. Sky is up high." The nurse should document the client's statement as which of the following speech alterations?
a. Echolalia
b. Word salad
c. Neologism
d. Clang association - d. Clang association
An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states "Im so worried that my mother is depressed" which of the following responses should the nurse make?
a. Everyone gets depressed from time to time.
b. You shouldn't worry about this because the depressive disorder is easily treated.
c. Older adults are usually diagnosed with the depressive disorder as they age.
d. Tell me the reasons you think your mother is depressed. - d. Tell me the reasons you think your mother is depressed.
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 care?
a. Meets own needs without manipulating others.
b. Initiates social interactions with caregivers.
c. Changes behavior as a result of peer pressure.
d. Acknowledges his delusions are not real. - b. Initiates social interactions with caregivers.
A nurse is providing behavior therapy for a client who has obsessive-compulsive disorder. 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. Snap a rubber band on your wrist when you think about checking the locks.
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. Keep a journal of how often you check the locks each night. - a. Snap a rubber band on your wrist when you think about checking the locks.
A nurse is caring for a client who is starting treatment for substance use disorder. Which of the following actions indicates the nurse is practicing the ethical principle of nonmaleficence?
a. Provide the client with quality care regardless of their ability to pay for treatment.
b. Educating the client about legal rights concerning treatment.
c. Withholding the prescribed medication that is causing adverse effects for the client.
d. Being truthful with the client about the manifestations of withdrawal. - c. Withholding the prescribed medication that is causing adverse effects for the client.
A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from other clients. Which of the following techniques should the nurse use?
a. Crisis intervention to decrease anxiety.
b. Aversion therapy to provide distraction
c. Positive reinforcement to increase desired behavior.
d. Systematic desensitization to extinguish the behavior. - c. Positive reinforcement to increase desired behavior.
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
a. Ask the client to discuss precipitating events
b. Speaks to the client in a high-pitched voice.
c. Place the client in seclusion
d. Have the client breathe into a paper bag. - d. Have the client breathe into a paper bag.
The nurse is caring for a client following a physical assault. The client states "I don't remember what happened to me." The nurse should recognize that the client is using which of the following defense mechanisms?
a. Repression
b. Displacement
c. Rationalization
d. Denial - a. Repression
A nurse is caring for a client who has anorexia nervosa. Which of the following findings require immediate intervention by the nurse?
a. +2 edema of the lower extremities [Show Less]