Post by Nursing Board 101 on Aug 18, 2010 13:33:12 GMT -5
1. An inpatient psychiatric client suddenly becomes loud and visibly anxious. What's the best action for the nurse to take?
a.)Summon help and escort the client to his room.
b.)Face the client squarely and say, "You must be quiet."
c.)Say, "Calm down; you're safe here."
d.)Say, "Let's go talk in your room."
D. RATIONALE: This response acknowledges that the client is important to the nurse and preserves the client's dignity with minimal restriction. The client doesn't need to be escorted to his room at this point; he hasn't yet been given a chance to go on his own. The nurse should use the least restrictive form of treatment at all times. Facing off with the client and demanding quiet is challenging. Telling the client to calm down is a placating response, which will likely increase the client's anxiety.
2. A voluntary client on an inpatient psychiatric unit has a history of auditory hallucinations and self-aggression. The nurse is talking with the client when the client suddenly jumps up and says, to no one in particular, "Get away from me." What's the nurse's best response?
a.)Escort the client to his room.
b.)Say, "I won't let them harm you."
c.)Sit quietly until the client becomes calm.
d.)Ask, "Who are you talking to?"
D. RATIONALE: This question aims to clarify the client's remark. Option A ignores what the client said and violates the client's right to the least restrictive environment. Option B assumes that the client is hallucinating. Option C fails to address what the client said.
3. A 35-year-old voluntary client suddenly begins yelling, throws a chair, and exhibits extreme agitation. Which of the following would be most important for the nurse to consider when planning an intervention?
a.)Because the client is a voluntary admission, restraints can't be used.
b.)The family must be called for permission to restrain the client.
c.)Restraint should be used as a last resort.
d.)Restraint can't be initiated until the physician is called.
C. RATIONALE: Restraint should always be used as a last resort, with the least restrictive measures used first. The criteria for restraint involve danger to self or others and don't exclude voluntary clients in emergencies. Unless a family member is a guardian, calling the family violates the client's confidentiality. In an emergency, the nurse may restrain a client before calling the physician.
4. Before forcing a client to take a medication, the nurse should give priority to:
a.)the client's danger to self or others.
b.)what the "voices" are saying to the client.
c.)whether the client's admission was voluntary.
d.)the client's insight into the illness.
A. RATIONALE: Client rights prohibit the forcing of medication unless the client poses a danger to self or others. If the client is judged incompetent, the guardian or court must approve the forced medication. The other options overrule the client's basic rights.
5. A client was admitted to the hospital 2 days ago for disrupting a town meeting, shouting religious delusions, and fighting with police. The client now refuses to take prescribed haloperidol (Haldol), saying, "I don't want it." Which response by the nurse would be best?
a.)"It will help you feel better."
b.)"You must take it or get an injection."
c.)"What are you afraid of?"
d.)"You sound concerned."
D. RATIONALE: The nurse's open-ended response encourages exploration. Option A is placating the client. Option B is threatening or, at least, too restrictive because the client hasn't exhibited dangerous behavior. Option C assumes that the client is afraid.
6. A client has been prescribed 75 mg of amitriptyline (Elavil) at bedtime and 15 mg of phenelzine (Nardil) three times per day. Which nursing action takes priority?
a.)Teaching the client about the adverse effects
b.)Calling the physician and questioning the order
c.)Instituting dietary restrictions
d.)Taking baseline vital signs
B. RATIONALE: Administering amitriptyline (a tricyclic antidepressant) and phenelzine (a monoamine oxidase [MAO] inhibitor) together could cause hypertension, tachycardia, or a potentially fatal reaction; the nurse should call the physician to check the order. The other options are important nursing actions, but they don't take priority over calling the physician.
7. A client on an inpatient psychiatric unit has been taking a tricyclic antidepressant without satisfactory results, so the physician changes to a monoamine oxidase (MAO) inhibitor. In evaluating the physician's order, the nurse must first be sure:
a.)adequate time has elapsed between discontinuing the first medication and beginning the second.
b.)the MAO inhibitor is begun at the same dosage as the tricyclic antidepressant.
c.)the client isn't suicidal.
d.)the client isn't allergic to cheese.
A. RATIONALE: Administering these two medications within a short time frame increases the risk of hypertension and hyperpyrexia. Dosages of MAO inhibitors can vary widely. The client's suicidal state and his allergy to cheese are irrelevant to the choice of drug or timing of administration.
8. A client reports no improvement in mood since beginning a regimen of 15 mg of tranylcypromine (Parnate) twice per day 1 week ago. Which of the following is the best nursing action?
a.)Say to the client, "The medication may need up to 4 weeks to take effect." b.)Say to the client, "You should feel the effects any day now."
c.)Consult with the physician about a dosage adjustment.
d.)Consult with the physician about a change of medication.
A. RATIONALE: MAO inhibitors, such as tranylcypromine, may take up to 4 weeks before improving the client's mood. Telling the client he will feel better soon is a vague promise that may create unrealistic expectations in the client. Consulting the physician is premature.
9. A client who has been hospitalized with depression is about to be discharged with a prescription of phenelzine (Nardil). In planning for discharge, the nurse should have a teaching plan that emphasizes:
a.)getting adequate rest.
b.)avoiding smoking.
c.)avoiding red wine.
d.)taking the drug with food or milk.
C. RATIONALE: A client taking phenelzine (a monoamine oxidase inhibitor) must avoid foods that contain tyramine (such as red wine) to prevent a hypertensive or hyperpyretic crisis. Getting adequate rest and avoiding smoking are healthy behaviors to reinforce, but they don't relate directly to phenelzine. Taking the drug with food and milk may be recommended if the medication causes GI distress, but it's secondary to teaching about the food restrictions.
10. The physician prescribes a monoamine oxidase (MAO) inhibitor for a client. Which of the following nursing diagnostic categories would be most appropriate to focus on during client teaching?
a.)Risk for injury
b.)Disturbed thought processes
c.)Deficient fluid volume
d.)Disturbed sleep pattern
A. RATIONALE: Because an MAO inhibitor can cause hypotension, the client must be given precautions related to driving. Disturbed thought processes and disturbed sleep pattern are possible but not likely, and they have lower priority than client safety. Excessive fluid volume is more likely than a deficit.
11. A nurse is teaching clients in an outpatient clinic about monoamine oxidase (MAO) inhibitors. The nurse would best evaluate the clients' understanding of how their medications work by noting:
a.)food selections.
b.)fluid intake.
c.)potential for self-harm.
d.)level of anxiety.
A. RATIONALE: A client taking an MAO inhibitor must avoid tyramine-rich foods to prevent a hypertensive or hyperpyretic crisis. Fluid intake, potential for self-harm, and level of anxiety are important assessment areas, but they don't relate directly to the clients' understanding of medications.
12. A hospitalized client taking 30 mg of tranylcypromine (Parnate) twice per day complains of a stiff neck and headache. Which action would be best for the nurse to take?
a.)Note the complaints as usual adverse effects.
b.)Withhold the next dose of medication.
c.)Administer an analgesic, as needed and as prescribed.
d.)Help the client relax.
B. RATIONALE: A stiff neck and headache may be prodromal symptoms of hypertensive crisis. Rather than dismiss the symptoms, the nurse should continue to assess them and consult the physician. Administering an analgesic and helping the client relax would be appropriate measures for a tension headache.
13. A client avoids leaving home to shop for groceries or complete other errands. At times the client feels "crazy" because of her fear. The client seeks out her neighbor, a nurse, for help. The nurse's assessment is phobic reaction. Which of the following statements about a phobia is true?
a.)The condition is a persistent, intrusive image that seems senseless to the person.
b.)It's important not to force the person to face the phobic object or situation. c.)The phobic condition can be cured by hypnosis.
d.)It's necessary to agree with the client's assessment that the phobia is silly.
B. RATIONALE: Forcing can provoke panic in the client; gradual desensitization is more successful. Option A defines an obsession. Hypnosis is used to help identify sources of anxiety responsible for amnesia and fugue and in establishing contact with a client who has multiple-personality disorder. Option D fails to acknowledge that the phobia serves a purpose for the person and thus inhibits insight.
14. A 76-year-old widowed mother of six is admitted to a long-term care facility with a diagnosis of organic mental disorder. Which of the following approaches would be most helpful for the nurse in meeting the client's needs?
a.)Make sure the client completes tasks that she begins.
b.)Maintain a gentle approach that doesn't set limits.
c.)Give the client alternative choices in making decisions.
d.)Simplify the environment as much as possible.
D. RATIONALE: This helps maintain the client's orientation and prevents further confusion from overstimulation. Making sure the client completes her tasks and giving her alternatives may confuse the client with organic mental disorder, who typically can't make decisions and is easily distracted. Maintaining a gentle approach that doesn't set limits is also incorrect; it's necessary for all staff members to consistently set limits to lower anxiety and increase orientation.
15. Which of the following snacks would be best for a client with anorexia nervosa who requires a high-protein, high-calorie diet?
a.)Chicken soup and crackers
b.)Doughnut and orange juice
c.)Egg salad and peanuts
d.)Cashews and strawberries
C. RATIONALE: Egg salad and peanuts are high in protein and calories. Chicken soup, crackers, and strawberries are low-protein, low-calorie foods. A doughnut and orange juice are low in protein.
16. What's the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior?
a.)Ineffective coping
b.)Imbalanced nutrition: Less than body requirements
c.)Imbalanced nutrition: More than body requirements
d.)Interrupted family processes
A. RATIONALE: The client's coping skills are ineffective when anxiety increases. The other diagnoses don't correspond to the observed behavior.
17. A 28-year-old accountant is admitted to the neurologic unit after a sudden onset of blindness the day before an important project is due for her boss. After preliminary evaluation and testing yields no positive findings, the physician's initial reaction is that the client may be demonstrating which defense mechanism?
a.)Repression
b.)Transference
c.)Reaction formation
d.)Conversion
D. RATIONALE: A person can convert unbearable feelings into a physical symptom with no organic cause. This defense mechanism usually manifests itself near the time of a traumatic or conflict-producing event. The symptom commonly provides attention or a means of escaping the conflict. Repression is a defense mechanism in which a person unconsciously keeps unwanted feelings from entering awareness. Transference involves the projection of feelings, thoughts, and wishes (positive or negative) onto someone, usually a therapist, who represents a figure from the person's past. Reaction formation is a means of alleviating unresolved conflicts between feelings or impulses by reinforcing one feeling and repressing another, thereby disguising the true feelings from the self.
18. A client with bipolar disorder, manic phase, who usually dresses conservatively, appears at breakfast with brightly colored cheeks, wearing a miniskirt, sheer blouse, and designer boots. Which of the following actions should the nurse take to deal with the client's attire?
a.)Redirect the client to her room and help her put on her more customary clothing. b.)Allow her the freedom to wear what she prefers for now.
c.)Remind the client of the dress code and the consequences of violation.
d.)Tell the client what to wear and advise her that she has lost the privilege of choosing her wardrobe.
A. RATIONALE: The nurse must protect the client from actions that will cause embarrassment when her condition improves. Allowing her the freedom to wear what she prefers doesn't remove the client from the embarrassing situation. Reminding the client of the dress code and telling her what to wear offer chastisement rather than guidance and support.
19. What's the most effective intervention for handling a client with an antisocial personality?
a.)Reason with the client.
b.)Set limits with the client.
c.)Ignore the client.
d.)Agree with the client.
B. RATIONALE: Limits must be maintained by all staff members and reinforced with restrictions when rules are broken. Reasoning with the client, ignoring him, and agreeing with him don't modify the unwanted behavior.
20. A client on the nursing unit, charged with child abuse, doesn't speak to the staff when approached. Which response by the nurse would be best?
a.)"If you need me, I'll be in the nurses' station."
b.)"You need to come to grips with what has happened."
c.)"Not speaking to the staff won't help your situation."
d.)"Admission to a psychiatric unit can be very difficult."
D. RATIONALE: This helps the client realize he's having difficulty without asking direct questions or focusing on specific behavior. Option A constitutes avoidance. Option B negates the client's feelings. Option C focuses on a specific behavior and doesn't convey sensitivity or caring.
21. After refusing to eat for 4 days, a 17-year-old college freshman is referred to the inpatient eating disorders unit of a general hospital. Her affect is flat, her eyes downcast, and her long blonde hair dull and limp. Her clothes hang loosely on her body, and she appears sullen and frightened. Her weight on admission is 89 lb (40.4 kg); her normal weight is 114 lb (52 kg). Which of the following assessments would best enable the nurse to develop a specific nursing diagnosis?
a.)Family history, including genograms
b.)Psychiatric history, including all hospital admissions
c.)Cardiac and respiratory history
d.)Weight loss history and general condition of skin, hair, and nails
D. RATIONALE: This will help the nurse formulate a nursing diagnosis that addresses the self-control and compliance needed to regain nutritional requirements. Other important areas to assess include nausea, vomiting, edema, and excretory functions. Family, psychiatric, and cardiac and respiratory histories may yield useful data, but they aren't as critical at this early stage.
22. A client is admitted for a suspected eating disorder. Which of the following statements would indicate that the client may be suffering from anorexia nervosa? a.)"I've gained 3 pounds in the last month."
b.)"I eat loads of spinach and yellow vegetables each day."
c.)"I'm a perfectionist, and I work hard to get A's."
d.)"I binge frequently in the morning and feel fat."
C. RATIONALE: Typically, the anorexic client works hard to achieve perfection and loses the ability to accept help. Option A refers to weight gain, which may indicate bulimia. Option B is atypical of anorexic clients, who have an intense fear of becoming obese and compulsively resist any attempts at eating. Binge eating (option D) is characteristic of bulimia (although bulimics tend to binge more frequently in the evening, and "feeling fat" is characteristic of anorexia).
23. Which of the following nursing interventions would be included in the care of a client with anorexia nervosa as therapy progresses?
a.)Let the client eat alone to avoid embarrassment.
b.)Weigh the client once a week in the same clothing.
c.)Monitor the client for self-destructive tendencies.
d.)Praise the client for "looking better," and remind the client that she isn't "too fat."
C. RATIONALE: Self-starvation is life-threatening; the client should be monitored for self-destructive tendencies. The nurse must stay with the client during meals to ensure that food is being eaten. The client should be weighed three times daily in light clothing to ensure accuracy. Praising the client for looking better could signal a power struggle with the client and the nurse's unconscious means of exerting control.
24. A client with a personality disorder exhibits manipulative behavior. Care planning for this client should include:
a.)freedom to do as the client chooses when behavior improves.
b.)limitations per unit rules without restrictions for broken rules.
c.)reasonable expectations with varying limits.
d.)verbal reinforcement when the client functions within established limits.
D. RATIONALE: This encourages the client to follow unit rules. The other options are inconsistent with changing manipulative behavior.
25. A 40-year-old woman is brought to the hospital by her husband, who states that she has refused to eat or get out of bed for 2 days. The woman says that she's tired all the time and doesn't feel up to going to work. Her admitting diagnosis is major depression. Which question would be most appropriate for the admitting nurse to ask?
a.)"What has been troubling you?"
b.)"Why do you dislike yourself?"
c.)"How do you feel about your life?"
d.)"What can we do to help?"
C. RATIONALE: The nurse must base nursing interventions on a client's perceived problems and feelings. Option A asks the client to draw a conclusion, which she may have difficulty doing at this time. Option B places the client in a defensive position. Option D is beyond the scope of the client's present abilities; she would probably rather have the nurse tell her how she can help herself.
26. A 24-year-old secretary is transferred to your psychiatric unit. Her husband says that she has been overeating and that she vomits soon after she eats. Her weight stays about the same, at 96 lb (44 kg). In planning care for the client, the nurse should anticipate which medical diagnosis?
a.)Anorexia nervosa
b.)Bulimia
c.)Klein-Levin syndrome
d.)Dysthymia
B. RATIONALE: The client exhibits the binging and purging typical of bulimia. Anorexia nervosa involves severe weight loss. Klein-Levin syndrome includes symptoms of a disturbed eating behavior, but the condition isn't characterized by the client's excessive concern with body shape and weight. Dysthymia is a type of depression.
27. For a client with bulimia, which assessment is least important in the care plan? a.)Observe the client after eating for 1 hour.
b.)Note the client's intake.
c.)Note changes in appetite.
d.)Note changes in respiratory rate.
D. RATIONALE: Respiratory rate usually isn't affected by bulimia. Observing the client after eating for 1 hour is important because it's the time that she's likely to vomit. Noting the client's intake and changes in her appetite are important factors to monitor in bulimia or any other eating disorder.
28. A client with personality disorder gets along poorly with the immediate family. The client's manipulative behavior most likely shows a failure to develop:
a.)intimate relationships.
b.)trust.
c.)industry.
d.)feelings of guilt.
B. RATIONALE: Manipulative behavior arises from a lack of trust. The client can't develop trust in others when he doesn't trust his own feelings. The other options can't be accomplished until trust is established.
29. A 32-year-old client is admitted to the unit. She states, "I'm a well-known, wealthy designer," and begins to order the nurses to prepare her bath while she orders her tray and telephones her colleagues. Her husband states that she's too busy to eat and sleep and is losing weight. Her admitting diagnosis is bipolar disorder, manic phase. For which of the following events should the nurse plan?
a.)Erratic and unpredictable behavior if challenged
b.)Boredom and the need for minute-to-minute activities
c.)Rapid mood changes from elation to depression
d.)One-to-one treatment to occupy the client's time
A. RATIONALE: Bipolar clients are often unpredictable and exhibit angry outbursts. The unit itself, with its regularly scheduled activities, may provide too much stimulation for the manic client. The course of illness wouldn't be expected to move rapidly through the manic-depressive-manic cycle, although the client should be observed for signs of depression.
30. A 32-year-old lawyer is admitted to the neurologic unit with a sudden onset of blindness the night before an important case is scheduled to go to trial. Tests reveal no physical findings. Which of the following is the best assessment of the client's anxiety? a.)It's diffuse and free floating.
b.)It's consciously experienced.
c.)It's localized and relieved by the blindness.
d.)It's projected onto the environment.
C. RATIONALE: Anxiety is relieved by keeping an internal need or conflict out of conscious awareness. The sudden onset of blindness without physiologic basis impairs normal activity and may promote the development of a chronic sick role. The anxiety-provoking impulse (the trial) is converted unconsciously into a functional symptom. The other options don't accurately describe the client's anxiety.
31. A 50-year-old client has been admitted for psychological testing after having been charged with physical abuse of a 7-year-old child. The client refuses to come to the day room, saying, "I don't want people to stare at me." Which response by the nurse is best? a.)"That's okay for now if that's what you want."
b.)"It will be easier for you if you face people as soon as possible."
c.)"The staff are the only people who know why you were admitted."
d.)"You're very hard on yourself.”
D. "RATIONALE: The client is in the hospital for treatment, not for judgment. Option A avoids dealing with the client's feelings. Option B gives false reassurance. Option C isn't necessarily true.
32. A 26-year-old office manager is hospitalized after developing acute leg pain. Diagnostic tests reveal no organic cause. What's the best long-term goal to include in this client's care plan?
a.)Develop insight into the client's psyche.
b.)Accelerate the client's developmental tasks.
c.)Restore the client's previous adaptive behaviors.
d.)Eliminate responsibility for the client's behavior.
C. RATIONALE: The treatment team should identify ways to reduce the anxiety that caused the client's symptoms, develop more positive ways of managing the stress, and prevent secondary gains from the hospitalization. Conversion symptoms aren't under voluntary control; they commonly represent a symbolic solution to an underlying conflict. The other options aren't closely related to the clinical picture of conversion disorder.
33. A 16-year-old student has been admitted to your psychiatric unit after fainting in physical education class. She has a diagnosis of anorexia nervosa, weighs 88 lb (40 kg), and is; 1.6 m tall. She has been weighing herself several times per day at home and has lost 30 lb (13.5 kg) in the past 3 months. Which nursing diagnosis would be most appropriate for the client?
a.)Disturbed thought processes
b.)Impaired adjustment
c.)Imbalanced nutrition: Less than body requirements
d.)Ineffective sexuality patterns
C. RATIONALE: Addressing the client's urgent physical needs is most important. The other diagnoses are possible with anorexia nervosa, but no data in the case study directly support them.
34. A client with antisocial personality disorder refuses to take a shower for 3 days. Which response by the nurse is best?
a.)"It's policy here for all clients to bathe daily."
b.)"It's time for your shower. I'll help you with it."
c.)"Don't worry about your shower until tomorrow."
d.)"Do you want people to make fun of you?"
B. RATIONALE: This response offers support and sets limits. Option A doesn't offer support. Option C allows the client to continue to break rules. Option D offers neither support nor respect.
35. A client with major depression states, "Everything is my fault, and I'd be better off dead." What's the priority nursing intervention?
a.)Assess the seriousness of the client's comment.
b.)Notify the psychiatrist of the client's verbalization.
c.)Assign staff members to a suicide watch.
d.)Engage the client in a no-suicide contract.
A. RATIONALE: This situation demands an accurate assessment of the client's suicide potential. The other options require more thorough assessment data before implementation.
36. An abused child is scheduled to be on the unit for 3 to 4 weeks. Which of the following assignments would be best for the child?
a.)Assign a different primary nurse to the child each day.
b.)Assign the primary nurse who is transferring next week to another unit.
c.)Assign the same primary nurse to the child each day of the hospital stay. d.)Assign a new primary nurse every 3 days.
C. RATIONALE: This will provide continuity of care and allow trust to develop. The other options aren't in the best interest of the client and won't further a trusting relationship.
37. A 38-year-old client is hospitalized with obsessive-compulsive disorder. On admission, she becomes nervous and asks to go to the bathroom to brush her teeth. Her husband says that she brushes her teeth at least 25 times per day. The nurse notes that the client's gums are inflamed and bleeding. What's the best nursing intervention?
a.)Have her stop brushing her teeth until the gums heal.
b.)Allow her to continue her routine of daily brushing.
c.)Monitor her dental care and set limits on the amount of daily brushing. d.)Brush her teeth for her.
C. RATIONALE: This allows the behavior that reduces anxiety for the client, but it sets limits as a first step in modifying the behavior. Having her stop brushing her teeth until her gums heal may leave the client unable to manage anxiety. Allowing her to continue her routine of daily brushing does nothing to change the behavior. Brushing her teeth for her treats the client like a toddler.
38. A client with a diagnosis of organic mental disorder becomes verbally and physically abusive when the nurse enters the client's room to assist with daily care. Which of the following interventions should the nurse engage in first?
a.)Check orders for physical and chemical restraints.
b.)Set firm limits verbally.
c.)Give clear directions while gently securing the client's arms from hitting the nurse. d.)Leave the room and let the angry, hostile behavior work itself out.
B. RATIONALE: Clear limits protect the client, staff, and others. A verbally and physically abusive client sometimes responds to verbal controls. Checking orders for physical and chemical restraints may be carried out, but not as a first priority. The goal is to use the least restrictive intervention needed to reduce anxiety and control behavior. Restraints would be used only as a last resort. Giving clear directions while gently securing the client's arms from hitting the nurse will likely escalate the hostile behavior. Additional staff help may be needed here. Leaving the room and letting the angry, hostile behavior work itself out could pose a safety problem. The client could fall or otherwise hurt herself in an attempt to strike out at the nurse or at an imagined threat.
39. A 2-year-old client is hospitalized with a fractured left arm, a concussion, and multiple bruises. The client appears quite withdrawn. The bruises appear to have occurred at different times, with some new and some nearly healed. Emergency department staff report suspected child abuse to the authorities. During an assessment, the nurse would expect which behavior in the child?
a.)Quiet and passive about pain
b.)Crying and sensitive to pain
c.)Happy to see new people
d.)Having good eye contact with the parents
A. RATIONALE: The abused child usually shows little emotion. The other options describe conspicuous behavior that an abused child would typically avoid, for fear of provoking further abuse.
40. A bulimic client admitted to the psychiatric unit suddenly shouts, "I want to leave right now. I'm not crazy and don't belong here." Which response should the nurse make? a.)"You can't go home until we cure your eating problems."
b.)"You seem upset; I'll stay with you."
c.)"Don't worry. You'll feel better tomorrow."
d.)"Let's talk about something more pleasant."
B. RATIONALE: This response acknowledges the client's feelings and offers support. Option A fails to acknowledge the client's feelings, and the client probably can't be kept against her will. Option C gives the client false reassurance and denies her feelings. Option D also denies the client's feelings.
41. A 22-year-old client has been diagnosed with antisocial personality disorder. She has been having problems since age 15, when she ran away from home. She has had two broken marriages, has been unable to keep a job for more than 2 months, and has had difficulties with the law because she has abused drugs and passed bad checks. Although the client has made all the telephone calls she is allowed for the day, she asks the nurse, "Can't I just make one more phone call?" Which response by the nurse would be best?
a.)"Okay, but don't talk too long."
b.)"Okay, if you promise to obey the rules the rest of the day."
c.)"No, you can't. The rules apply equally to everyone, and you are asking to break them."
d.)"No, you can't. Go watch television."
C. RATIONALE: This response enforces the limits and explains why the client can't use the phone. Options A and B don't encourage the client to follow the rules. Option D doesn't explain why the client's request is being denied.
42. A client with anorexia nervosa who is on bed rest stares at her dinner tray. She has made little effort to eat. Which statement by the nurse would be most therapeutic? a.)"You should be ashamed of yourself. There are starving people who would love that food."
b.)"Hurry up with your tray. I have several more clients to see."
c.)"Don't worry. You can eat more tomorrow."
d.)"I'll stay with you while you eat and help you fill out tomorrow's menu."
D. RATIONALE: This response shows that the nurse values the client, and it promotes eating by having the client select food preferences. Option A doesn't promote eating; in her weakened condition, the client probably doesn't care about world hunger. Option B implies that the nurse is too busy to spend time with the client. Option C placates the client and permits her to continue poor eating habits.
43. A client is hospitalized after experiencing sudden-onset paralysis. Diagnostic tests reveal no positive physical findings. What's a likely cause?
a.)Demonstrated organic pathology
b.)Intense feelings of worthlessness
c.)A primary and conscious need for attention
d.)An involuntary attempt to solve a conflict
D. RATIONALE: In conversion disorder, the client unconsciously converts anxiety-provoking impulses into functional symptoms. Although primary gains occur (the anxiety-provoking impulse is avoided), the internal need or conflict is usually kept out of conscious awareness. No physical pathology was discovered. Anxiety, rather than feelings of worthlessness, is the primary motivator. A hallmark of conversion disorder is that its attention-seeking activities aren't conscious. The typical client can't see the connection, obvious to others, between the anxiety-laden situation and the sudden illness that provides a means of escape.
44. A 19-year-old male just arrived on the psychiatric unit from the emergency department. His medical diagnosis is personality disorder, and he exhibits manipulative behavior. As the nurse reviews the unit rules with him, the client asks, "Can I go to the snack shop just one time, and then I'll answer whatever you want?" What's the nurse's best response?
a.)"Okay, but hurry up. I need to finish your assessment."
b.)"Okay, but only for 5 minutes."
c.)"No, you can't go."
d.)"No, you can't go. The rules here are for everyone."
D. RATIONALE: This response sets limits with an appropriate explanation. Options A and B give in to the manipulative behavior. Option C doesn't explain the purpose of the refusal.
45. A client with major depression begins to improve and participates in treatment programs on the unit. The nurse should recognize that the client is ready for discharge when the client:
a.)asks the staff for advice about how to handle the future.
b.)speaks to the employer about a return date to work.
c.)identifies personal weaknesses and plans to work on them.
d.)discusses plans to return home and continue outpatient treatment.
D. RATIONALE: The client's plan to return home and continue treatment as an outpatient indicates responsibility for her own level of wellness. Asking the staff for advice implies that the client is still unable or unwilling to accept responsibility for herself. Although talking to her boss is a positive step, it won't help the client comprehensively. Identifying and working on weak areas represent short-term steps taken before discharge.
46. Which of the following concepts about anorexia nervosa should the nurse consider in understanding a client's cry for help?
a.)Focus on anorexia as an effort to gain status and resolve conflict
b.)Rejection of food as a way to obtain love and care from parents
c.)Use of eating behavior to resolve conscious sexual needs
d.)Avoidance of eating as a response to voices that threaten the client
B. RATIONALE: An anorexic client rigidly controls potentially disabling anxiety by controlling eating to the point of self-destructiveness. Conflicts most commonly encountered are issues of identity, separation, and autonomy; parents are commonly central figures in these struggles. The function of anorexia nervosa as a means of dealing with anxiety is itself rooted in conflict. The client can't seek resolution of the conflict without therapeutic intervention. Far from embracing sexuality, the typical anorexic client stops menstruating, avoids adolescent sexual issues, and hides her body under baggy clothing. An anorexic client usually doesn't experience hallucinations.
47. A noticeably withdrawn 14-year-old female client is being treated on the unit for anorexia nervosa. Which nursing assessments should be made daily?
a.)Edema of the legs
b.)Pulse and blood pressure elevation
c.)Frequent binging and purging
d.)Level of depression and anxiety
D. RATIONALE: Depression and anxiety commonly accompany anorexia nervosa. Edema of the legs and pulse and blood pressure elevation aren't associated with eating disorders. Frequent binging and purging is typical of bulimia.
48. A 76-year-old client is admitted to a long-term care facility with a diagnosis of organic mental disorder. The client has been wearing the same dirty, torn undergarments for several days. The nurse contacts family members to bring in clean clothing. Which of the following interventions would best prevent further regression in the client's personal hygiene habits?
a.)Encourage the client to perform as much self-care as possible.
b.)Make the client assume responsibility for physical care.
c.)Assign a staff member to take over the client's physical care.
d.)Accept the client's desire to go without bathing and to wear dirty clothing.
A. RATIONALE: Clients with organically based problems tend to fluctuate in their capabilities. Encouraging self-care will help increase the client's orientation, provide a safe environment, and promote a trusting relationship with the nurse. Option B is unreasonable, given the client's possible confusion; self-esteem and independence must be developed as much as possible, but with assistance in activities of daily living. Option C restricts the client's independence. Option D promotes poor hygiene.
49. A 37-year-old man with a history of schizophrenia is having hallucinations. He shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" Which response by the nurse is best?
a.)"No, I don't. Quit talking foolishly."
b.)"Yes, I see them, and they sure are big ones."
c.)"No, I don't see them, but I believe that you do see them."
d.)"Let's go to the recreation room."
C. RATIONALE: The nurse should present reality while acknowledging that the hallucination is real to the client. Option A presents reality but demeans the client in doing so. Option B encourages the client's hallucinations. Option D changes the subject and ignores the issue.
50. Teaching for a client taking antipsychotic medication should include which of the following instructions?
a.)Take the medication with antacid to prevent upset stomach.
b.)Get fresh air and plenty of sunshine.
c.)If a dose is missed, take two the next time.
d.)Avoid abrupt withdrawal of the medication.
D. RATIONALE: Abrupt withdrawal could result in nausea or seizures. Antacids decrease the effectiveness of antipsychotics when taken within 1 hour of the drug. Because of the adverse effect of photosensitivity, clients taking antipsychotic drugs should avoid sun exposure. Doubling up the medication could cause an overdose.
51. A client on an inpatient psychiatric unit at a community mental health center is pacing the hallway and appears agitated. When the nurse approaches him, he says loudly, "Leave me alone." What's the nurse's best approach?
a.)Say "Okay" and walk away.
b.)Summon help in case the client becomes aggressive.
c.)Say nothing and pace with the client.
d.)Say "You sound upset. I'd like to help."
D. RATIONALE: This demonstrates the nurse's concern and encourages the client to discuss feelings. Given the likelihood of an increase in anxiety level, the client shouldn't be left alone. Summoning help may escalate the client's anxiety. Saying nothing and pacing with the client acknowledge the client's emotional state.
52. A 23-year-old married homemaker has been on the psychiatric unit for 2 days. She has a history of bipolar disorder and came to the hospital in the manic phase. She stopped taking her medication (lithium carbonate [Eskalith]) 2 weeks ago. Which of the following findings is the nurse least likely to see?
a.)Flight of ideas
b.)Delusions of grandeur
c.)Increased appetite
d.)Restlessness
C. RATIONALE: The manic client is usually unwilling or unable to slow down enough to eat. Flight of ideas, delusions of grandeur, and restlessness are associated with the manic phase.
53. Which of the following instructions is most important for a client taking lithium carbonate [Eskalith]?
a.)Limit fluids to 1 qt (1,500 ml) daily.
b.)Maintain a high fluid intake.
c.)Take advantage of the warm weather by getting outside exercise when possible. d.)When feeling a cold coming on, take over-the-counter (OTC) medications.
B. RATIONALE: Clients taking lithium need to maintain a high fluid intake. Fluids shouldn't be limited. Photosensitivity occurs with lithium use, and increased activity in warm weather could increase sodium loss, predisposing the client to a toxic reaction to lithium. The client shouldn't take OTC drugs without the physician's approval.
54. What's the best room assignment for a client with bipolar disorder, manic phase?
a.)Alone, at the end of the hall
b.)Alone, nearest the nurses' station
c.)With another bipolar client at the end of the hall
d.)With a depressed 40-year-old near the nurses' station
A. RATIONALE: Such an assignment provides a quiet environment without the additional stimuli of a roommate and the noise of the nurses' station. The other options provide too much stimulation and would likely increase the client's manic behavior.
55. A 28-year-old single female arrives at a mental health clinic complaining of depression. She states that she has been feeling numb and empty most of the time and has little energy to perform her usual activities. She has experienced these difficulties since the death of her best friend 6 months ago. Which of the following is the nurse's best response?
a.)Tell the client that the physician will prescribe an antidepressant and she will feel better.
b.)Encourage the client to get on with her life and stop feeling sorry for herself.
c.)Advise the client that it isn't unusual for grieving and loss to continue for quite some time.
d.)Suggest that the client return in 3 months if the feelings persist.
C. RATIONALE: This provides the client with validation and support for her feelings. The other options neither validate the client's bereavement nor allow her to resolve them.
56. A 50-year-old bookkeeper arrives for a follow-up visit after a severe wrist fracture 3 months ago. The tearful client expresses helplessness, frustration, and anxiety, stating that the injury was the worst experience of her life. The client's level of function is severely compromised. She has been unable to return to work and is currently receiving disability payments. What's the nurse's best response?
a.)"I can see how upsetting this is for you. It must be very difficult to be unable to function independently."
b.)"I know how you must feel. I broke my arm a long time ago, but I am fine now. You'll be as good as new soon."
c.)"You are overly anxious. These injuries take time to heal, and you just have to be patient."
d.)"I know it's difficult, but you'll just have to get hold of yourself and get on with your life."
A. RATIONALE: This provides validation for the client's feelings. The other options don't offer the client either support or the opportunity to discuss her feelings.
57. While making rounds in a senior citizens' housing complex, the visiting nurse discovers one of her clients sobbing in her darkened apartment. On questioning the client, an 85-year-old widow, the nurse learns that her pet cat of 15 years had been put to sleep the day before. What's the nurse's best response?
a.)"It shouldn't be hard to find another cat. You'll feel better once you have another pet." b.)"It was only a cat. Why are you allowing yourself to be so upset? It would be different if it were a person."
c.)"I'm so sorry that your pet had to be put to sleep. I know how important your cat was to you."
d.)"It's probably best for the cat because it was so old and ill."
C. RATIONALE: This offers support and empathy and enhances the grieving process. The other options don't address the client's need for support and grieving.
58. A 35-year-old married truck driver presents at a mental health clinic. Since losing his job 2 weeks ago, he has slept only a few hours a night and has lost 10 lb (4.5 kg). Pale and haggard, he has trouble answering questions and is easily distracted. What's the best action for the nurse to take?
a.)Ask him if he has tried to find another job.
b.)Determine his current and previous level of function and conduct a mental status examination.
c.)Ask him if he has ever sought mental health counseling before and whether he's taking any medications.
d.)Ask about his family's reaction to his job loss.
B. RATIONALE: This action assesses the client's current level of function, emotional state, and stability. The other options don't offer the client support or assist in evaluating his current status.
59. A 50-year-old single male is brought to the crisis unit by the police after having escaped unharmed from his apartment, which was destroyed by a fire caused by his smoking in bed. The nurse observes the client sitting silently, almost motionless. Several other clients in the waiting room have commented about the heavy odor of smoke around the man. Which of the following is the nurse's best approach to the client?
a.)"Would you like to change your clothes? The odor of smoke must be very disturbing."
b.)"You have been through a very difficult experience. Let's move into the office so that we can talk."
c.)"I hope you have learned your lesson today and have given up cigarettes."
d.)"You must consider yourself one very lucky man."
B. RATIONALE: The client is immobilized by his near-death experience, the loss of his home, and his responsibility for these situations based on his smoking. Because he can't make decisions at this point, the nurse's direction is appropriate and therapeutic. It also provides a tactful way to alleviate the odor of smoke in the waiting room. The other options don't provide support or direction for the client during this crisis.
60. A 19-year-old nursing student preparing for final exams arrives at the student health center, accompanied by two friends. She hasn't slept all night, is sobbing hysterically, is hyperventilating, and states that she "can't go on." Which of the following is the best response for the nurse to make?
a.)"Relax, we've all felt this way. You'll get through it."
b.)"Perhaps you need more time to study. Have you discussed this with your advisor?"
c.)"You're pretty upset right now. Studying for finals can be very stressful. Let's work on a plan that might be helpful."
d.)"You need to calm down. Nurses have to learn to take a lot of stress."
C. RATIONALE: This provides support, reassurance, and a concrete plan for dealing with the issues. Option A provides false reassurance. Option B is unrealistic; a client in high anxiety can't think coherently enough to respond to such a suggestion. Option D negates the client's feelings and may cause further anxiety.
a.)Summon help and escort the client to his room.
b.)Face the client squarely and say, "You must be quiet."
c.)Say, "Calm down; you're safe here."
d.)Say, "Let's go talk in your room."
D. RATIONALE: This response acknowledges that the client is important to the nurse and preserves the client's dignity with minimal restriction. The client doesn't need to be escorted to his room at this point; he hasn't yet been given a chance to go on his own. The nurse should use the least restrictive form of treatment at all times. Facing off with the client and demanding quiet is challenging. Telling the client to calm down is a placating response, which will likely increase the client's anxiety.
2. A voluntary client on an inpatient psychiatric unit has a history of auditory hallucinations and self-aggression. The nurse is talking with the client when the client suddenly jumps up and says, to no one in particular, "Get away from me." What's the nurse's best response?
a.)Escort the client to his room.
b.)Say, "I won't let them harm you."
c.)Sit quietly until the client becomes calm.
d.)Ask, "Who are you talking to?"
D. RATIONALE: This question aims to clarify the client's remark. Option A ignores what the client said and violates the client's right to the least restrictive environment. Option B assumes that the client is hallucinating. Option C fails to address what the client said.
3. A 35-year-old voluntary client suddenly begins yelling, throws a chair, and exhibits extreme agitation. Which of the following would be most important for the nurse to consider when planning an intervention?
a.)Because the client is a voluntary admission, restraints can't be used.
b.)The family must be called for permission to restrain the client.
c.)Restraint should be used as a last resort.
d.)Restraint can't be initiated until the physician is called.
C. RATIONALE: Restraint should always be used as a last resort, with the least restrictive measures used first. The criteria for restraint involve danger to self or others and don't exclude voluntary clients in emergencies. Unless a family member is a guardian, calling the family violates the client's confidentiality. In an emergency, the nurse may restrain a client before calling the physician.
4. Before forcing a client to take a medication, the nurse should give priority to:
a.)the client's danger to self or others.
b.)what the "voices" are saying to the client.
c.)whether the client's admission was voluntary.
d.)the client's insight into the illness.
A. RATIONALE: Client rights prohibit the forcing of medication unless the client poses a danger to self or others. If the client is judged incompetent, the guardian or court must approve the forced medication. The other options overrule the client's basic rights.
5. A client was admitted to the hospital 2 days ago for disrupting a town meeting, shouting religious delusions, and fighting with police. The client now refuses to take prescribed haloperidol (Haldol), saying, "I don't want it." Which response by the nurse would be best?
a.)"It will help you feel better."
b.)"You must take it or get an injection."
c.)"What are you afraid of?"
d.)"You sound concerned."
D. RATIONALE: The nurse's open-ended response encourages exploration. Option A is placating the client. Option B is threatening or, at least, too restrictive because the client hasn't exhibited dangerous behavior. Option C assumes that the client is afraid.
6. A client has been prescribed 75 mg of amitriptyline (Elavil) at bedtime and 15 mg of phenelzine (Nardil) three times per day. Which nursing action takes priority?
a.)Teaching the client about the adverse effects
b.)Calling the physician and questioning the order
c.)Instituting dietary restrictions
d.)Taking baseline vital signs
B. RATIONALE: Administering amitriptyline (a tricyclic antidepressant) and phenelzine (a monoamine oxidase [MAO] inhibitor) together could cause hypertension, tachycardia, or a potentially fatal reaction; the nurse should call the physician to check the order. The other options are important nursing actions, but they don't take priority over calling the physician.
7. A client on an inpatient psychiatric unit has been taking a tricyclic antidepressant without satisfactory results, so the physician changes to a monoamine oxidase (MAO) inhibitor. In evaluating the physician's order, the nurse must first be sure:
a.)adequate time has elapsed between discontinuing the first medication and beginning the second.
b.)the MAO inhibitor is begun at the same dosage as the tricyclic antidepressant.
c.)the client isn't suicidal.
d.)the client isn't allergic to cheese.
A. RATIONALE: Administering these two medications within a short time frame increases the risk of hypertension and hyperpyrexia. Dosages of MAO inhibitors can vary widely. The client's suicidal state and his allergy to cheese are irrelevant to the choice of drug or timing of administration.
8. A client reports no improvement in mood since beginning a regimen of 15 mg of tranylcypromine (Parnate) twice per day 1 week ago. Which of the following is the best nursing action?
a.)Say to the client, "The medication may need up to 4 weeks to take effect." b.)Say to the client, "You should feel the effects any day now."
c.)Consult with the physician about a dosage adjustment.
d.)Consult with the physician about a change of medication.
A. RATIONALE: MAO inhibitors, such as tranylcypromine, may take up to 4 weeks before improving the client's mood. Telling the client he will feel better soon is a vague promise that may create unrealistic expectations in the client. Consulting the physician is premature.
9. A client who has been hospitalized with depression is about to be discharged with a prescription of phenelzine (Nardil). In planning for discharge, the nurse should have a teaching plan that emphasizes:
a.)getting adequate rest.
b.)avoiding smoking.
c.)avoiding red wine.
d.)taking the drug with food or milk.
C. RATIONALE: A client taking phenelzine (a monoamine oxidase inhibitor) must avoid foods that contain tyramine (such as red wine) to prevent a hypertensive or hyperpyretic crisis. Getting adequate rest and avoiding smoking are healthy behaviors to reinforce, but they don't relate directly to phenelzine. Taking the drug with food and milk may be recommended if the medication causes GI distress, but it's secondary to teaching about the food restrictions.
10. The physician prescribes a monoamine oxidase (MAO) inhibitor for a client. Which of the following nursing diagnostic categories would be most appropriate to focus on during client teaching?
a.)Risk for injury
b.)Disturbed thought processes
c.)Deficient fluid volume
d.)Disturbed sleep pattern
A. RATIONALE: Because an MAO inhibitor can cause hypotension, the client must be given precautions related to driving. Disturbed thought processes and disturbed sleep pattern are possible but not likely, and they have lower priority than client safety. Excessive fluid volume is more likely than a deficit.
11. A nurse is teaching clients in an outpatient clinic about monoamine oxidase (MAO) inhibitors. The nurse would best evaluate the clients' understanding of how their medications work by noting:
a.)food selections.
b.)fluid intake.
c.)potential for self-harm.
d.)level of anxiety.
A. RATIONALE: A client taking an MAO inhibitor must avoid tyramine-rich foods to prevent a hypertensive or hyperpyretic crisis. Fluid intake, potential for self-harm, and level of anxiety are important assessment areas, but they don't relate directly to the clients' understanding of medications.
12. A hospitalized client taking 30 mg of tranylcypromine (Parnate) twice per day complains of a stiff neck and headache. Which action would be best for the nurse to take?
a.)Note the complaints as usual adverse effects.
b.)Withhold the next dose of medication.
c.)Administer an analgesic, as needed and as prescribed.
d.)Help the client relax.
B. RATIONALE: A stiff neck and headache may be prodromal symptoms of hypertensive crisis. Rather than dismiss the symptoms, the nurse should continue to assess them and consult the physician. Administering an analgesic and helping the client relax would be appropriate measures for a tension headache.
13. A client avoids leaving home to shop for groceries or complete other errands. At times the client feels "crazy" because of her fear. The client seeks out her neighbor, a nurse, for help. The nurse's assessment is phobic reaction. Which of the following statements about a phobia is true?
a.)The condition is a persistent, intrusive image that seems senseless to the person.
b.)It's important not to force the person to face the phobic object or situation. c.)The phobic condition can be cured by hypnosis.
d.)It's necessary to agree with the client's assessment that the phobia is silly.
B. RATIONALE: Forcing can provoke panic in the client; gradual desensitization is more successful. Option A defines an obsession. Hypnosis is used to help identify sources of anxiety responsible for amnesia and fugue and in establishing contact with a client who has multiple-personality disorder. Option D fails to acknowledge that the phobia serves a purpose for the person and thus inhibits insight.
14. A 76-year-old widowed mother of six is admitted to a long-term care facility with a diagnosis of organic mental disorder. Which of the following approaches would be most helpful for the nurse in meeting the client's needs?
a.)Make sure the client completes tasks that she begins.
b.)Maintain a gentle approach that doesn't set limits.
c.)Give the client alternative choices in making decisions.
d.)Simplify the environment as much as possible.
D. RATIONALE: This helps maintain the client's orientation and prevents further confusion from overstimulation. Making sure the client completes her tasks and giving her alternatives may confuse the client with organic mental disorder, who typically can't make decisions and is easily distracted. Maintaining a gentle approach that doesn't set limits is also incorrect; it's necessary for all staff members to consistently set limits to lower anxiety and increase orientation.
15. Which of the following snacks would be best for a client with anorexia nervosa who requires a high-protein, high-calorie diet?
a.)Chicken soup and crackers
b.)Doughnut and orange juice
c.)Egg salad and peanuts
d.)Cashews and strawberries
C. RATIONALE: Egg salad and peanuts are high in protein and calories. Chicken soup, crackers, and strawberries are low-protein, low-calorie foods. A doughnut and orange juice are low in protein.
16. What's the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior?
a.)Ineffective coping
b.)Imbalanced nutrition: Less than body requirements
c.)Imbalanced nutrition: More than body requirements
d.)Interrupted family processes
A. RATIONALE: The client's coping skills are ineffective when anxiety increases. The other diagnoses don't correspond to the observed behavior.
17. A 28-year-old accountant is admitted to the neurologic unit after a sudden onset of blindness the day before an important project is due for her boss. After preliminary evaluation and testing yields no positive findings, the physician's initial reaction is that the client may be demonstrating which defense mechanism?
a.)Repression
b.)Transference
c.)Reaction formation
d.)Conversion
D. RATIONALE: A person can convert unbearable feelings into a physical symptom with no organic cause. This defense mechanism usually manifests itself near the time of a traumatic or conflict-producing event. The symptom commonly provides attention or a means of escaping the conflict. Repression is a defense mechanism in which a person unconsciously keeps unwanted feelings from entering awareness. Transference involves the projection of feelings, thoughts, and wishes (positive or negative) onto someone, usually a therapist, who represents a figure from the person's past. Reaction formation is a means of alleviating unresolved conflicts between feelings or impulses by reinforcing one feeling and repressing another, thereby disguising the true feelings from the self.
18. A client with bipolar disorder, manic phase, who usually dresses conservatively, appears at breakfast with brightly colored cheeks, wearing a miniskirt, sheer blouse, and designer boots. Which of the following actions should the nurse take to deal with the client's attire?
a.)Redirect the client to her room and help her put on her more customary clothing. b.)Allow her the freedom to wear what she prefers for now.
c.)Remind the client of the dress code and the consequences of violation.
d.)Tell the client what to wear and advise her that she has lost the privilege of choosing her wardrobe.
A. RATIONALE: The nurse must protect the client from actions that will cause embarrassment when her condition improves. Allowing her the freedom to wear what she prefers doesn't remove the client from the embarrassing situation. Reminding the client of the dress code and telling her what to wear offer chastisement rather than guidance and support.
19. What's the most effective intervention for handling a client with an antisocial personality?
a.)Reason with the client.
b.)Set limits with the client.
c.)Ignore the client.
d.)Agree with the client.
B. RATIONALE: Limits must be maintained by all staff members and reinforced with restrictions when rules are broken. Reasoning with the client, ignoring him, and agreeing with him don't modify the unwanted behavior.
20. A client on the nursing unit, charged with child abuse, doesn't speak to the staff when approached. Which response by the nurse would be best?
a.)"If you need me, I'll be in the nurses' station."
b.)"You need to come to grips with what has happened."
c.)"Not speaking to the staff won't help your situation."
d.)"Admission to a psychiatric unit can be very difficult."
D. RATIONALE: This helps the client realize he's having difficulty without asking direct questions or focusing on specific behavior. Option A constitutes avoidance. Option B negates the client's feelings. Option C focuses on a specific behavior and doesn't convey sensitivity or caring.
21. After refusing to eat for 4 days, a 17-year-old college freshman is referred to the inpatient eating disorders unit of a general hospital. Her affect is flat, her eyes downcast, and her long blonde hair dull and limp. Her clothes hang loosely on her body, and she appears sullen and frightened. Her weight on admission is 89 lb (40.4 kg); her normal weight is 114 lb (52 kg). Which of the following assessments would best enable the nurse to develop a specific nursing diagnosis?
a.)Family history, including genograms
b.)Psychiatric history, including all hospital admissions
c.)Cardiac and respiratory history
d.)Weight loss history and general condition of skin, hair, and nails
D. RATIONALE: This will help the nurse formulate a nursing diagnosis that addresses the self-control and compliance needed to regain nutritional requirements. Other important areas to assess include nausea, vomiting, edema, and excretory functions. Family, psychiatric, and cardiac and respiratory histories may yield useful data, but they aren't as critical at this early stage.
22. A client is admitted for a suspected eating disorder. Which of the following statements would indicate that the client may be suffering from anorexia nervosa? a.)"I've gained 3 pounds in the last month."
b.)"I eat loads of spinach and yellow vegetables each day."
c.)"I'm a perfectionist, and I work hard to get A's."
d.)"I binge frequently in the morning and feel fat."
C. RATIONALE: Typically, the anorexic client works hard to achieve perfection and loses the ability to accept help. Option A refers to weight gain, which may indicate bulimia. Option B is atypical of anorexic clients, who have an intense fear of becoming obese and compulsively resist any attempts at eating. Binge eating (option D) is characteristic of bulimia (although bulimics tend to binge more frequently in the evening, and "feeling fat" is characteristic of anorexia).
23. Which of the following nursing interventions would be included in the care of a client with anorexia nervosa as therapy progresses?
a.)Let the client eat alone to avoid embarrassment.
b.)Weigh the client once a week in the same clothing.
c.)Monitor the client for self-destructive tendencies.
d.)Praise the client for "looking better," and remind the client that she isn't "too fat."
C. RATIONALE: Self-starvation is life-threatening; the client should be monitored for self-destructive tendencies. The nurse must stay with the client during meals to ensure that food is being eaten. The client should be weighed three times daily in light clothing to ensure accuracy. Praising the client for looking better could signal a power struggle with the client and the nurse's unconscious means of exerting control.
24. A client with a personality disorder exhibits manipulative behavior. Care planning for this client should include:
a.)freedom to do as the client chooses when behavior improves.
b.)limitations per unit rules without restrictions for broken rules.
c.)reasonable expectations with varying limits.
d.)verbal reinforcement when the client functions within established limits.
D. RATIONALE: This encourages the client to follow unit rules. The other options are inconsistent with changing manipulative behavior.
25. A 40-year-old woman is brought to the hospital by her husband, who states that she has refused to eat or get out of bed for 2 days. The woman says that she's tired all the time and doesn't feel up to going to work. Her admitting diagnosis is major depression. Which question would be most appropriate for the admitting nurse to ask?
a.)"What has been troubling you?"
b.)"Why do you dislike yourself?"
c.)"How do you feel about your life?"
d.)"What can we do to help?"
C. RATIONALE: The nurse must base nursing interventions on a client's perceived problems and feelings. Option A asks the client to draw a conclusion, which she may have difficulty doing at this time. Option B places the client in a defensive position. Option D is beyond the scope of the client's present abilities; she would probably rather have the nurse tell her how she can help herself.
26. A 24-year-old secretary is transferred to your psychiatric unit. Her husband says that she has been overeating and that she vomits soon after she eats. Her weight stays about the same, at 96 lb (44 kg). In planning care for the client, the nurse should anticipate which medical diagnosis?
a.)Anorexia nervosa
b.)Bulimia
c.)Klein-Levin syndrome
d.)Dysthymia
B. RATIONALE: The client exhibits the binging and purging typical of bulimia. Anorexia nervosa involves severe weight loss. Klein-Levin syndrome includes symptoms of a disturbed eating behavior, but the condition isn't characterized by the client's excessive concern with body shape and weight. Dysthymia is a type of depression.
27. For a client with bulimia, which assessment is least important in the care plan? a.)Observe the client after eating for 1 hour.
b.)Note the client's intake.
c.)Note changes in appetite.
d.)Note changes in respiratory rate.
D. RATIONALE: Respiratory rate usually isn't affected by bulimia. Observing the client after eating for 1 hour is important because it's the time that she's likely to vomit. Noting the client's intake and changes in her appetite are important factors to monitor in bulimia or any other eating disorder.
28. A client with personality disorder gets along poorly with the immediate family. The client's manipulative behavior most likely shows a failure to develop:
a.)intimate relationships.
b.)trust.
c.)industry.
d.)feelings of guilt.
B. RATIONALE: Manipulative behavior arises from a lack of trust. The client can't develop trust in others when he doesn't trust his own feelings. The other options can't be accomplished until trust is established.
29. A 32-year-old client is admitted to the unit. She states, "I'm a well-known, wealthy designer," and begins to order the nurses to prepare her bath while she orders her tray and telephones her colleagues. Her husband states that she's too busy to eat and sleep and is losing weight. Her admitting diagnosis is bipolar disorder, manic phase. For which of the following events should the nurse plan?
a.)Erratic and unpredictable behavior if challenged
b.)Boredom and the need for minute-to-minute activities
c.)Rapid mood changes from elation to depression
d.)One-to-one treatment to occupy the client's time
A. RATIONALE: Bipolar clients are often unpredictable and exhibit angry outbursts. The unit itself, with its regularly scheduled activities, may provide too much stimulation for the manic client. The course of illness wouldn't be expected to move rapidly through the manic-depressive-manic cycle, although the client should be observed for signs of depression.
30. A 32-year-old lawyer is admitted to the neurologic unit with a sudden onset of blindness the night before an important case is scheduled to go to trial. Tests reveal no physical findings. Which of the following is the best assessment of the client's anxiety? a.)It's diffuse and free floating.
b.)It's consciously experienced.
c.)It's localized and relieved by the blindness.
d.)It's projected onto the environment.
C. RATIONALE: Anxiety is relieved by keeping an internal need or conflict out of conscious awareness. The sudden onset of blindness without physiologic basis impairs normal activity and may promote the development of a chronic sick role. The anxiety-provoking impulse (the trial) is converted unconsciously into a functional symptom. The other options don't accurately describe the client's anxiety.
31. A 50-year-old client has been admitted for psychological testing after having been charged with physical abuse of a 7-year-old child. The client refuses to come to the day room, saying, "I don't want people to stare at me." Which response by the nurse is best? a.)"That's okay for now if that's what you want."
b.)"It will be easier for you if you face people as soon as possible."
c.)"The staff are the only people who know why you were admitted."
d.)"You're very hard on yourself.”
D. "RATIONALE: The client is in the hospital for treatment, not for judgment. Option A avoids dealing with the client's feelings. Option B gives false reassurance. Option C isn't necessarily true.
32. A 26-year-old office manager is hospitalized after developing acute leg pain. Diagnostic tests reveal no organic cause. What's the best long-term goal to include in this client's care plan?
a.)Develop insight into the client's psyche.
b.)Accelerate the client's developmental tasks.
c.)Restore the client's previous adaptive behaviors.
d.)Eliminate responsibility for the client's behavior.
C. RATIONALE: The treatment team should identify ways to reduce the anxiety that caused the client's symptoms, develop more positive ways of managing the stress, and prevent secondary gains from the hospitalization. Conversion symptoms aren't under voluntary control; they commonly represent a symbolic solution to an underlying conflict. The other options aren't closely related to the clinical picture of conversion disorder.
33. A 16-year-old student has been admitted to your psychiatric unit after fainting in physical education class. She has a diagnosis of anorexia nervosa, weighs 88 lb (40 kg), and is; 1.6 m tall. She has been weighing herself several times per day at home and has lost 30 lb (13.5 kg) in the past 3 months. Which nursing diagnosis would be most appropriate for the client?
a.)Disturbed thought processes
b.)Impaired adjustment
c.)Imbalanced nutrition: Less than body requirements
d.)Ineffective sexuality patterns
C. RATIONALE: Addressing the client's urgent physical needs is most important. The other diagnoses are possible with anorexia nervosa, but no data in the case study directly support them.
34. A client with antisocial personality disorder refuses to take a shower for 3 days. Which response by the nurse is best?
a.)"It's policy here for all clients to bathe daily."
b.)"It's time for your shower. I'll help you with it."
c.)"Don't worry about your shower until tomorrow."
d.)"Do you want people to make fun of you?"
B. RATIONALE: This response offers support and sets limits. Option A doesn't offer support. Option C allows the client to continue to break rules. Option D offers neither support nor respect.
35. A client with major depression states, "Everything is my fault, and I'd be better off dead." What's the priority nursing intervention?
a.)Assess the seriousness of the client's comment.
b.)Notify the psychiatrist of the client's verbalization.
c.)Assign staff members to a suicide watch.
d.)Engage the client in a no-suicide contract.
A. RATIONALE: This situation demands an accurate assessment of the client's suicide potential. The other options require more thorough assessment data before implementation.
36. An abused child is scheduled to be on the unit for 3 to 4 weeks. Which of the following assignments would be best for the child?
a.)Assign a different primary nurse to the child each day.
b.)Assign the primary nurse who is transferring next week to another unit.
c.)Assign the same primary nurse to the child each day of the hospital stay. d.)Assign a new primary nurse every 3 days.
C. RATIONALE: This will provide continuity of care and allow trust to develop. The other options aren't in the best interest of the client and won't further a trusting relationship.
37. A 38-year-old client is hospitalized with obsessive-compulsive disorder. On admission, she becomes nervous and asks to go to the bathroom to brush her teeth. Her husband says that she brushes her teeth at least 25 times per day. The nurse notes that the client's gums are inflamed and bleeding. What's the best nursing intervention?
a.)Have her stop brushing her teeth until the gums heal.
b.)Allow her to continue her routine of daily brushing.
c.)Monitor her dental care and set limits on the amount of daily brushing. d.)Brush her teeth for her.
C. RATIONALE: This allows the behavior that reduces anxiety for the client, but it sets limits as a first step in modifying the behavior. Having her stop brushing her teeth until her gums heal may leave the client unable to manage anxiety. Allowing her to continue her routine of daily brushing does nothing to change the behavior. Brushing her teeth for her treats the client like a toddler.
38. A client with a diagnosis of organic mental disorder becomes verbally and physically abusive when the nurse enters the client's room to assist with daily care. Which of the following interventions should the nurse engage in first?
a.)Check orders for physical and chemical restraints.
b.)Set firm limits verbally.
c.)Give clear directions while gently securing the client's arms from hitting the nurse. d.)Leave the room and let the angry, hostile behavior work itself out.
B. RATIONALE: Clear limits protect the client, staff, and others. A verbally and physically abusive client sometimes responds to verbal controls. Checking orders for physical and chemical restraints may be carried out, but not as a first priority. The goal is to use the least restrictive intervention needed to reduce anxiety and control behavior. Restraints would be used only as a last resort. Giving clear directions while gently securing the client's arms from hitting the nurse will likely escalate the hostile behavior. Additional staff help may be needed here. Leaving the room and letting the angry, hostile behavior work itself out could pose a safety problem. The client could fall or otherwise hurt herself in an attempt to strike out at the nurse or at an imagined threat.
39. A 2-year-old client is hospitalized with a fractured left arm, a concussion, and multiple bruises. The client appears quite withdrawn. The bruises appear to have occurred at different times, with some new and some nearly healed. Emergency department staff report suspected child abuse to the authorities. During an assessment, the nurse would expect which behavior in the child?
a.)Quiet and passive about pain
b.)Crying and sensitive to pain
c.)Happy to see new people
d.)Having good eye contact with the parents
A. RATIONALE: The abused child usually shows little emotion. The other options describe conspicuous behavior that an abused child would typically avoid, for fear of provoking further abuse.
40. A bulimic client admitted to the psychiatric unit suddenly shouts, "I want to leave right now. I'm not crazy and don't belong here." Which response should the nurse make? a.)"You can't go home until we cure your eating problems."
b.)"You seem upset; I'll stay with you."
c.)"Don't worry. You'll feel better tomorrow."
d.)"Let's talk about something more pleasant."
B. RATIONALE: This response acknowledges the client's feelings and offers support. Option A fails to acknowledge the client's feelings, and the client probably can't be kept against her will. Option C gives the client false reassurance and denies her feelings. Option D also denies the client's feelings.
41. A 22-year-old client has been diagnosed with antisocial personality disorder. She has been having problems since age 15, when she ran away from home. She has had two broken marriages, has been unable to keep a job for more than 2 months, and has had difficulties with the law because she has abused drugs and passed bad checks. Although the client has made all the telephone calls she is allowed for the day, she asks the nurse, "Can't I just make one more phone call?" Which response by the nurse would be best?
a.)"Okay, but don't talk too long."
b.)"Okay, if you promise to obey the rules the rest of the day."
c.)"No, you can't. The rules apply equally to everyone, and you are asking to break them."
d.)"No, you can't. Go watch television."
C. RATIONALE: This response enforces the limits and explains why the client can't use the phone. Options A and B don't encourage the client to follow the rules. Option D doesn't explain why the client's request is being denied.
42. A client with anorexia nervosa who is on bed rest stares at her dinner tray. She has made little effort to eat. Which statement by the nurse would be most therapeutic? a.)"You should be ashamed of yourself. There are starving people who would love that food."
b.)"Hurry up with your tray. I have several more clients to see."
c.)"Don't worry. You can eat more tomorrow."
d.)"I'll stay with you while you eat and help you fill out tomorrow's menu."
D. RATIONALE: This response shows that the nurse values the client, and it promotes eating by having the client select food preferences. Option A doesn't promote eating; in her weakened condition, the client probably doesn't care about world hunger. Option B implies that the nurse is too busy to spend time with the client. Option C placates the client and permits her to continue poor eating habits.
43. A client is hospitalized after experiencing sudden-onset paralysis. Diagnostic tests reveal no positive physical findings. What's a likely cause?
a.)Demonstrated organic pathology
b.)Intense feelings of worthlessness
c.)A primary and conscious need for attention
d.)An involuntary attempt to solve a conflict
D. RATIONALE: In conversion disorder, the client unconsciously converts anxiety-provoking impulses into functional symptoms. Although primary gains occur (the anxiety-provoking impulse is avoided), the internal need or conflict is usually kept out of conscious awareness. No physical pathology was discovered. Anxiety, rather than feelings of worthlessness, is the primary motivator. A hallmark of conversion disorder is that its attention-seeking activities aren't conscious. The typical client can't see the connection, obvious to others, between the anxiety-laden situation and the sudden illness that provides a means of escape.
44. A 19-year-old male just arrived on the psychiatric unit from the emergency department. His medical diagnosis is personality disorder, and he exhibits manipulative behavior. As the nurse reviews the unit rules with him, the client asks, "Can I go to the snack shop just one time, and then I'll answer whatever you want?" What's the nurse's best response?
a.)"Okay, but hurry up. I need to finish your assessment."
b.)"Okay, but only for 5 minutes."
c.)"No, you can't go."
d.)"No, you can't go. The rules here are for everyone."
D. RATIONALE: This response sets limits with an appropriate explanation. Options A and B give in to the manipulative behavior. Option C doesn't explain the purpose of the refusal.
45. A client with major depression begins to improve and participates in treatment programs on the unit. The nurse should recognize that the client is ready for discharge when the client:
a.)asks the staff for advice about how to handle the future.
b.)speaks to the employer about a return date to work.
c.)identifies personal weaknesses and plans to work on them.
d.)discusses plans to return home and continue outpatient treatment.
D. RATIONALE: The client's plan to return home and continue treatment as an outpatient indicates responsibility for her own level of wellness. Asking the staff for advice implies that the client is still unable or unwilling to accept responsibility for herself. Although talking to her boss is a positive step, it won't help the client comprehensively. Identifying and working on weak areas represent short-term steps taken before discharge.
46. Which of the following concepts about anorexia nervosa should the nurse consider in understanding a client's cry for help?
a.)Focus on anorexia as an effort to gain status and resolve conflict
b.)Rejection of food as a way to obtain love and care from parents
c.)Use of eating behavior to resolve conscious sexual needs
d.)Avoidance of eating as a response to voices that threaten the client
B. RATIONALE: An anorexic client rigidly controls potentially disabling anxiety by controlling eating to the point of self-destructiveness. Conflicts most commonly encountered are issues of identity, separation, and autonomy; parents are commonly central figures in these struggles. The function of anorexia nervosa as a means of dealing with anxiety is itself rooted in conflict. The client can't seek resolution of the conflict without therapeutic intervention. Far from embracing sexuality, the typical anorexic client stops menstruating, avoids adolescent sexual issues, and hides her body under baggy clothing. An anorexic client usually doesn't experience hallucinations.
47. A noticeably withdrawn 14-year-old female client is being treated on the unit for anorexia nervosa. Which nursing assessments should be made daily?
a.)Edema of the legs
b.)Pulse and blood pressure elevation
c.)Frequent binging and purging
d.)Level of depression and anxiety
D. RATIONALE: Depression and anxiety commonly accompany anorexia nervosa. Edema of the legs and pulse and blood pressure elevation aren't associated with eating disorders. Frequent binging and purging is typical of bulimia.
48. A 76-year-old client is admitted to a long-term care facility with a diagnosis of organic mental disorder. The client has been wearing the same dirty, torn undergarments for several days. The nurse contacts family members to bring in clean clothing. Which of the following interventions would best prevent further regression in the client's personal hygiene habits?
a.)Encourage the client to perform as much self-care as possible.
b.)Make the client assume responsibility for physical care.
c.)Assign a staff member to take over the client's physical care.
d.)Accept the client's desire to go without bathing and to wear dirty clothing.
A. RATIONALE: Clients with organically based problems tend to fluctuate in their capabilities. Encouraging self-care will help increase the client's orientation, provide a safe environment, and promote a trusting relationship with the nurse. Option B is unreasonable, given the client's possible confusion; self-esteem and independence must be developed as much as possible, but with assistance in activities of daily living. Option C restricts the client's independence. Option D promotes poor hygiene.
49. A 37-year-old man with a history of schizophrenia is having hallucinations. He shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" Which response by the nurse is best?
a.)"No, I don't. Quit talking foolishly."
b.)"Yes, I see them, and they sure are big ones."
c.)"No, I don't see them, but I believe that you do see them."
d.)"Let's go to the recreation room."
C. RATIONALE: The nurse should present reality while acknowledging that the hallucination is real to the client. Option A presents reality but demeans the client in doing so. Option B encourages the client's hallucinations. Option D changes the subject and ignores the issue.
50. Teaching for a client taking antipsychotic medication should include which of the following instructions?
a.)Take the medication with antacid to prevent upset stomach.
b.)Get fresh air and plenty of sunshine.
c.)If a dose is missed, take two the next time.
d.)Avoid abrupt withdrawal of the medication.
D. RATIONALE: Abrupt withdrawal could result in nausea or seizures. Antacids decrease the effectiveness of antipsychotics when taken within 1 hour of the drug. Because of the adverse effect of photosensitivity, clients taking antipsychotic drugs should avoid sun exposure. Doubling up the medication could cause an overdose.
51. A client on an inpatient psychiatric unit at a community mental health center is pacing the hallway and appears agitated. When the nurse approaches him, he says loudly, "Leave me alone." What's the nurse's best approach?
a.)Say "Okay" and walk away.
b.)Summon help in case the client becomes aggressive.
c.)Say nothing and pace with the client.
d.)Say "You sound upset. I'd like to help."
D. RATIONALE: This demonstrates the nurse's concern and encourages the client to discuss feelings. Given the likelihood of an increase in anxiety level, the client shouldn't be left alone. Summoning help may escalate the client's anxiety. Saying nothing and pacing with the client acknowledge the client's emotional state.
52. A 23-year-old married homemaker has been on the psychiatric unit for 2 days. She has a history of bipolar disorder and came to the hospital in the manic phase. She stopped taking her medication (lithium carbonate [Eskalith]) 2 weeks ago. Which of the following findings is the nurse least likely to see?
a.)Flight of ideas
b.)Delusions of grandeur
c.)Increased appetite
d.)Restlessness
C. RATIONALE: The manic client is usually unwilling or unable to slow down enough to eat. Flight of ideas, delusions of grandeur, and restlessness are associated with the manic phase.
53. Which of the following instructions is most important for a client taking lithium carbonate [Eskalith]?
a.)Limit fluids to 1 qt (1,500 ml) daily.
b.)Maintain a high fluid intake.
c.)Take advantage of the warm weather by getting outside exercise when possible. d.)When feeling a cold coming on, take over-the-counter (OTC) medications.
B. RATIONALE: Clients taking lithium need to maintain a high fluid intake. Fluids shouldn't be limited. Photosensitivity occurs with lithium use, and increased activity in warm weather could increase sodium loss, predisposing the client to a toxic reaction to lithium. The client shouldn't take OTC drugs without the physician's approval.
54. What's the best room assignment for a client with bipolar disorder, manic phase?
a.)Alone, at the end of the hall
b.)Alone, nearest the nurses' station
c.)With another bipolar client at the end of the hall
d.)With a depressed 40-year-old near the nurses' station
A. RATIONALE: Such an assignment provides a quiet environment without the additional stimuli of a roommate and the noise of the nurses' station. The other options provide too much stimulation and would likely increase the client's manic behavior.
55. A 28-year-old single female arrives at a mental health clinic complaining of depression. She states that she has been feeling numb and empty most of the time and has little energy to perform her usual activities. She has experienced these difficulties since the death of her best friend 6 months ago. Which of the following is the nurse's best response?
a.)Tell the client that the physician will prescribe an antidepressant and she will feel better.
b.)Encourage the client to get on with her life and stop feeling sorry for herself.
c.)Advise the client that it isn't unusual for grieving and loss to continue for quite some time.
d.)Suggest that the client return in 3 months if the feelings persist.
C. RATIONALE: This provides the client with validation and support for her feelings. The other options neither validate the client's bereavement nor allow her to resolve them.
56. A 50-year-old bookkeeper arrives for a follow-up visit after a severe wrist fracture 3 months ago. The tearful client expresses helplessness, frustration, and anxiety, stating that the injury was the worst experience of her life. The client's level of function is severely compromised. She has been unable to return to work and is currently receiving disability payments. What's the nurse's best response?
a.)"I can see how upsetting this is for you. It must be very difficult to be unable to function independently."
b.)"I know how you must feel. I broke my arm a long time ago, but I am fine now. You'll be as good as new soon."
c.)"You are overly anxious. These injuries take time to heal, and you just have to be patient."
d.)"I know it's difficult, but you'll just have to get hold of yourself and get on with your life."
A. RATIONALE: This provides validation for the client's feelings. The other options don't offer the client either support or the opportunity to discuss her feelings.
57. While making rounds in a senior citizens' housing complex, the visiting nurse discovers one of her clients sobbing in her darkened apartment. On questioning the client, an 85-year-old widow, the nurse learns that her pet cat of 15 years had been put to sleep the day before. What's the nurse's best response?
a.)"It shouldn't be hard to find another cat. You'll feel better once you have another pet." b.)"It was only a cat. Why are you allowing yourself to be so upset? It would be different if it were a person."
c.)"I'm so sorry that your pet had to be put to sleep. I know how important your cat was to you."
d.)"It's probably best for the cat because it was so old and ill."
C. RATIONALE: This offers support and empathy and enhances the grieving process. The other options don't address the client's need for support and grieving.
58. A 35-year-old married truck driver presents at a mental health clinic. Since losing his job 2 weeks ago, he has slept only a few hours a night and has lost 10 lb (4.5 kg). Pale and haggard, he has trouble answering questions and is easily distracted. What's the best action for the nurse to take?
a.)Ask him if he has tried to find another job.
b.)Determine his current and previous level of function and conduct a mental status examination.
c.)Ask him if he has ever sought mental health counseling before and whether he's taking any medications.
d.)Ask about his family's reaction to his job loss.
B. RATIONALE: This action assesses the client's current level of function, emotional state, and stability. The other options don't offer the client support or assist in evaluating his current status.
59. A 50-year-old single male is brought to the crisis unit by the police after having escaped unharmed from his apartment, which was destroyed by a fire caused by his smoking in bed. The nurse observes the client sitting silently, almost motionless. Several other clients in the waiting room have commented about the heavy odor of smoke around the man. Which of the following is the nurse's best approach to the client?
a.)"Would you like to change your clothes? The odor of smoke must be very disturbing."
b.)"You have been through a very difficult experience. Let's move into the office so that we can talk."
c.)"I hope you have learned your lesson today and have given up cigarettes."
d.)"You must consider yourself one very lucky man."
B. RATIONALE: The client is immobilized by his near-death experience, the loss of his home, and his responsibility for these situations based on his smoking. Because he can't make decisions at this point, the nurse's direction is appropriate and therapeutic. It also provides a tactful way to alleviate the odor of smoke in the waiting room. The other options don't provide support or direction for the client during this crisis.
60. A 19-year-old nursing student preparing for final exams arrives at the student health center, accompanied by two friends. She hasn't slept all night, is sobbing hysterically, is hyperventilating, and states that she "can't go on." Which of the following is the best response for the nurse to make?
a.)"Relax, we've all felt this way. You'll get through it."
b.)"Perhaps you need more time to study. Have you discussed this with your advisor?"
c.)"You're pretty upset right now. Studying for finals can be very stressful. Let's work on a plan that might be helpful."
d.)"You need to calm down. Nurses have to learn to take a lot of stress."
C. RATIONALE: This provides support, reassurance, and a concrete plan for dealing with the issues. Option A provides false reassurance. Option B is unrealistic; a client in high anxiety can't think coherently enough to respond to such a suggestion. Option D negates the client's feelings and may cause further anxiety.