a client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to:
1.move the client next to the nurse's
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2.use a night light and turn off the television
3.keep up the television and a soft light on during the night.
4.play soft music during the night and maintain a well-lit room
2.use a night light and turn off the television
a nurse is collecting data on a client who is actively hallucinating. WHich nursing statement would be therapeutic at this time?
1."I know you feel they are out to get you, but its not true"
2."I can hear the voice and she wants you to come to dinner"
3."sometimes people hear things or voices others can't hear"
4."I talked to the voices you're hearing and they won't hurt you now"
3."sometimes people hear things or voices others can't hear"
a nurse is caring for a client with a diagnosis of depression. the nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by:
1.poor dietary choices
2.lack of exercise and poor diet
3.inadequate dietary intake and dehydration
4.psychomotor retardation and side effects of medication
4.psychomotor retardation and side effects of medication
a client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. the client's mother begins to cry and states, "my child's brain will be destroyed. How can the doctor do this?" the nurse makes which therapeutic response?
1."it sounds as though you need to speak to the psychiatrist."
2."perhaps you'd like to see the ECT room and speak to the staff"
3.your child has decided to have this treatment. you should be supportive of the decision"
4.it sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"
4.it sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"
a client who is diagnosed with pedophilia and has been recently paroled as a sex offender says "Im in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it" which of the following is an appropriate response by the nurse?
1. "when children are hurt as you hurt them, people want you isolated"
2. "you're lucky it doesn't escalate into something pretty scary after your crime"
3."you understand that people fear for their children, but you're feeling unfairly treated?"
4."you seem angry, but you have committed serious crimes against several children, so your neighbors are frightened?"
3."you understand that people fear for their children, but you're feeling unfairly treated?"
a nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states:
1. "my medications won't make me anxious"
2. "i'll go to a support group and talk so that I won't hurt anyone."
3."I won't get anxious or hear things if I get enough sleep and eat well"
4."I can call my therapist when Im hallucinating so that I can talk about my feelings and plans and not hurt anyone"
4."I can call my therapist when Im hallucinating so that I can talk about my feelings and plans and not hurt anyone"
a nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to:
1.Provide safety for the client and other clients on the unit
2.Provide the clients on the unit with a sense of comfort and safety
3. Assist the staff in caring for the client in a controlled environment
4.offer the client a less-stimulating area to calm down and gain control
1.Provide safety for the client and other clients on the unit
a nurse is caring for a client diagnosed with catatonic stupor. the client is lying on the bed, with the body pulled into a fetal position. the appropriate nursing intervention is which of the following?
1.ask direct questions to encourage talking.
2.leave the client alone and intermittently check on him.
3.sit beside the client in silence and verbalize occasional open-ended questions.
4.take the client into the dayroom with other clients so they can help watch him
3.sit beside the client in silence and verbalize occasional open-ended questions.
a mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive" and "hangs out with the wrong crowd". In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother:
1.restrict the daughters socializing time with her friends.
2.restrict the amount of chocolate and caffeine products in the home
3.keep her daughter out of school until she can adjust to the school environment
4.consider taking time from work to help her daughter readjust to the home environment.
2.restrict the amount of chocolate and caffeine products in the home
a client is unwilling to go out of the house for fear of "doing something crazy in public". Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has:
1.agoraphobia
2.hematophobia
3.claustrophobia
4.hypochondriasis
1.agoraphobia
a client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on:
1.weight loss
2.sleep patterns
3.medication compliance
4.onset of the crying spells
1.weight loss
a client was admitted to a medical unit with acute blindness. many tests are performed and there seems to be no organic reason why this client cannot see. the nurse latter learns that the client became blind after witnessing a hit-and-run car crash, in which a family of three was killed. the nurse suspects that the client may be experiencing a:
1.psychosis
2.repression
3.conversion disorder
4.dissociative disorder
3.conversion disorder
a manic client announces to everyone in the day room that a stripper is coming to perform that evening. when the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to:
1.escort the manic client to his or her room
2.orient the client to time, person, and place
3.tell the client that the behavior is not appropriate
4.tell the client that smoking privileges are revoked for 24 hours
1.escort the manic client to his or her room
a nurse notes documentation in a client's record that the client is experiencing delusions of persecution. THe nurse understands that these types of delusions are characteristics of which of the following?
1.the false belief that one is a very powerful person.
2.the false belief that one is very important person
3.the false belief that one is being singled out for harm by others
4.the false belief that one's partner is going out with other people
3.the false belief that one is being singled out for harm by others
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
1.Communicate expected behaviors to the client
2.ensure that the client knows that he or she is not in charge of the nursing unit
3.assist the client in developing means of setting limits on personal behavior
4.follow through about the consequences of behavior in a nonpunitive manner
5.enforce rules and inform the client that he or she will not be allowed to attend therapy groups.
6.be clear with the client regarding the consequences of exceeding limits set regarding behavior
1.Communicate expected behaviors to the client
3.assist the client in developing means of setting limits on personal behavior
4.follow through about the consequences of behavior in a non-punitive manner
6.be clear with the client regarding the consequences of exceeding limits set regarding behavior
a nurse is caring for an older adult client who has recently lost her husband. The client says, "no one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?
1."right! why not just pack it in?"
2."that seems rather unlikely to me"
3."i don't believe that, and neither do you"
4."you must be feeling all alone at this point"
4."you must be feeling all alone at this point"
a nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. THe nurse avoids which intervention in the plan of care?
1.facing the client when providing care
2.ensuring that a security officer is within the immediate area
3.keeping the door to the client's room open when with the client
4.assigning the client to a room at the end of the hall to prevent disturbing the other clients.
4.assigning the client to a room at the end of the hall to prevent disturbing the other clients.
which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?
1.the client gives away a prized CD and a cherished autographed picture of the performer
2.the client runs out of the therapy group swearing at the group leader and then runs to her room
3.the client gets angry with her roommate when the roommate borrows her clothes without asking
4.the client becomes angry while speaking on the telephone and slams the receiver down on the hook.
1.the client gives away a prized CD and a cherished autographed picture of the performer
a client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. the nurse's most important aspect of care is to maintain client safety and plans to:
1.request that a peer remain with the client at all times
2.remove the client's clothing and place the client in a hospital gown.
3.assign a staff member to the client who will remain with him or her at all times
4.admit the client to a seclusion room where all potentially dangerous articles are removed
will remain with him or her at all times
the police arrive at the emergency room with a client who has seriously lacerated both wrists. the initial nursing action is to:
1.administer an anti anxiety agent
2.examine and treat the wound sites
3.secure and record a detailed history
4.encourage and assist the client to vent feelings
2.examine and treat the wound sites [Show Less]