HESI Computerized Adaptive Testing (CAT) Test Bank With Rationales

Correct1 HESI Computerized Adaptive Testing (CAT) LATEST VERSION. A team approach is used to help a 6-year-old boy with attention deficit-hyperactivity disorder (ADHD). What behaviors indicate that the interventions have been effective? Select all that apply. 1 2 Correct4 Correct5 Is able to wait his turn when in line with others A nurse is assigned to lead a relaxation group. Which techniques should the nurse incorporate? Select all that apply. Meditation Mental imagery 3 Token economy 4 Operant conditioning Correct5 Deep-breathing exercises Correct2 Has an increased attention span in school Is no longer enuretic during the night Incorrect3 Has fun playing with toys by himself Is not inhibited by rules or routines How should a nurse characterize a sudden terrorist act that causes the deaths of thousands of adults and children and negatively affects their families, friends, communities, and the nation? 1 2 Correct4 Adventitious A nurse has just completed a mental status examination on a newly admitted psychiatric client and returns to the nurses’ station to document the results. The nurse reflects on the client’s drawn-out explanation of the reason for the admission and concludes that excessive detail was given before the client eventually answered the questions. What mental process does the nurse identify? 1 Flight of ideas Circumstantiality When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? Select all that apply. Correct1 Projection Suppression 3 Sublimation 4 Incorrect2 Correct2 Maturational Incorrect3 Situational Recurring Incorrect 1. A client whose auditory hallucinations are saying, “They’re going to get you.” Correct 2. A manic client who has spent the last 8 hours refusing liquids and pacing around the unit. Incorrect 3. A depressed client who shares with the roommate that the client is “very happy today.” Correct 4. A cognitively impaired older adult who believes that the deceased spouse will visit today. Incorrect1 Correct5 Rationalization The registered nurse managing the care of four clients is determining individual priorities. Place the following clients in order of priority, with 1 as the highest priority. A newly admitted client with schizophrenia has a treatment plan that includes participation in a physical activity group for several days before assignment to an analytical group. The basis for this decision is that the client will do what? Develop skills in managing leisure time 2 Have time to develop insight into personal problems 3 Be too disruptive to benefit from group therapy at this time Correct4 Cultivate trust before moving into a potentially anxiety-producing group The mother of an 18-year-old man comes to the local mental health center. She is extremely upset because of her son’s behavior since the young man returned from his freshman year at college. He takes his brother’s clothing, comes in at all hours, and refuses to get a job. Sometimes he is happy and outgoing, but at other times he is withdrawn. The mother asks why her son is like this. While contemplating this situation, the nurse considers that which adjectives usually apply to adolescents? 1 Anxious and unhappy Identification Contacting family members to provide support Incorrect1 Discussing the legal ramifications of not pressing charges Correct4 2 A young adult is being treated in the emergency department for injuries sustained as a result of physical battering by her partner. On learning that there is a history of such abuse, the nurse plans which tertiary nursing interventions? Select all that apply. 2 Correct4 Correct5 Providing her with information regarding local domestic violence shelters Certain questions are applicable in determining nursing negligence. Select all that apply. Correct1 "Was reasonable care provided?" Correct2 "Was there a breach of nursing duty?" "Was there an act of omission that resulted in harm?" "Except for the nurse’s action, would the injury have occurred?" Correct3 Identifying the benefits of attending a support group for battered women Offering to discuss the abusive behavior with the woman's partner Incorrect3 Impulsive and self-centered Correct3 Angry and irresponsible Incorrect 1. Administer appropriate medications as prescribed if indicated. Incorrect 2. Move all clients to a safe, controlled area. Incorrect 3. Activate the unit's fire alarm system. Incorrect 4. Place the manic client in a quiet environment with low stimulation. Ensuring the safety of the milieu is the priority. The fire alarm is activated immediately after all clients and staff have been removed from the area of the fire. The next intervention is providing the manic client with a quiet, low-stimulation environment. If the nursing assessment indicates a need for medication to manage the client's behavior, it should then be administered. The parents of a toddler with recently diagnosed moderate cognitive impairment state, "Our child should be able to attend college with help and medication." What should the nurse conclude? 1 A nurse is caring for a 20-year-old client. According to Erikson’s developmental psychosocial theory, what is expected by 20 years of age? 1 Correct3 Having a coherent sense of self and plans for self-actualization A small fire has been set in the dayroom garbage can by a client who is currently demonstrating manic behavior. Place the following nursing interventions in the appropriate order to best ensure client and milieu safety. After an electroconvulsive therapy treatment, a client complains of loss of memory. What is the nurse's best response? Being creative and productive and having concern for others Incorrect2 Having the capacity for love and a commitment to work Denial is being used as a defense mechanism. Correct2 They accept the child’s diagnosis. Incorrect1 Correct1 "This is temporary; your memory will return after the therapy is done." A nurse facilitating a support group of widows and widowers recalls that research indicates that the probability of a spouse having a pathological or morbid grief response will be greater in what case? The couple had an ambivalent relationship. Correct2 The cause of the spouse's death was suicide. Having male staff interact with the client only in public areas of the unit Incorrect1 Based on the following documentation, to best address the client's needs, what is the nurse's initial intervention? Correct3 Correct2 Offering the client a high-protein drink every hour in a quiet area of the unit A client who had to be cut out of a car after a motor vehicle collision has no visible physical effects from the ordeal. The client responds to the emergency department nurse's questions factually in a soft voice with a composed manner. What may this behavior indicate about the client? Correct1 The client is controlling the expression of feelings. An older woman comes to the mental health clinic and reports, "I've not been feeling right and haven't been able to sleep or eat since my husband died 8 months ago." The nurse determines that the client is experiencing grief associated with the loss of the husband. What supports this conclusion? 1 Inability to talk about her loss 2 Difficulty in expressing her loss Lack of sleep and the presence of symptoms of depression A primary nurse notes that a client has become jaundiced after 2 weeks of antipsychotic drug therapy. The nurse continues to administer the antipsychotic until the primary healthcare provider can be consulted. What does the nurse manager conclude about this situation? Correct1 Jaundice is sufficient reason to discontinue the antipsychotic. Which individual is coping with issues concerning dependence versus independence? 1 Infant Toddler Correct2 Denial Incorrect1 Correct1 Correct1 A nurse is teaching a group of recently hired staff members about defense mechanisms. An example given is Scarlett O'Hara, in the movie Gone with the Wind, who said, "I'll think about that tomorrow." What defense mechanism does this statement reflect? 2 Splitting 3 Repression A client's hands are raw and bloody from a ritual involving frequent hand washing. Which defense mechanism does the nurse identify? Correct1 Undoing A nurse working in a mental health clinic has a caseload composed of a number of individuals and families. Which members of the caseload are at the greatest risk for mental health problems? A family with a new baby, a divorced man, and a recently retired older woman A parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old child, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? Select all that apply. By denying beating the child Correct2 By avoiding talking about the situation By asking where the other three children are 4 Incorrect3 Correct1 Incorrect1 Correct5 By exhibiting an emotional response that is inconsistent with the degree of injury According to Erikson, a person’s adjustment to the period of senescence will depend largely on the adjustment the individual made to which earlier developmental stage? 1 Trust versus mistrust Industry versus inferiority 3 Identity versus role confusion Correct4 Generativity versus stagnation During the eighth session of a therapy group, a member who talks frequently is interrupted by one who doesn't. When the interrupting person is finished talking, the one who usually contributes says, "I'm so glad that you feel like talking today." While saying this, the client sits rigidly and looks angry. How should the nurse respond? Comment on the interrupted client's angry behavior and pleasant words. A practitioner prescribes routine checks of the client's lithium level to be performed. How many hours after the last dose of lithium should the nurse plan to obtain the blood specimen? 2 to 4 2 4 to 6 3 6 to 8 Correct4 Incorrect2 By expressing excessive concern for the child Incorrect1 Incorrect1 A psychiatric unit uses a behavioral approach to determine a client's level of privileges. Which factor should a nurse use to determine whether an increase in privileges is warranted? 1 Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse? A 25-year-old man who is mimicking the use of a machine gun in front of the nurse’s station 2 Correct3 A client who was sexually assaulted and is aware of the possible legal implications decides to seek prosecution of the rapist. The nurse carefully listens and documents all assessments. This is done because with a charge of rape the burden of proof has which implication? The burden of proof rests with the health team. 2 It is on the defendant to prove innocence. 3 Burden of proof must be established before the case will be heard. Correct4 The burden of proof rests with the criminal justice system in collaboration with the victim. A 17-year-old client is diagnosed with leukemia. Which statements by the teenager reflect Piaget’s cognitive processes associated with adolescence? Select all that apply. A 50-year-old woman who is pacing back and forth across the dayroom and picking fights with other clients A 45-year-old man who is sitting quietly in the corner, watching the movements of other clients Performing hygiene activities independently Correct2 Stating that the depression is lifting 8 to 12 Incorrect 1. Advise her of the potential related health risks and the treatments that are available. Incorrect 2. Talk to her in a calm, nonjudgmental manner. Incorrect 3. Encourage her to express her feelings concerning the assault. Incorrect 4. Provide care for her laceration and contusions. Incorrect 5. Provide her with clear, concise explanations of care that will be provided. The establishment of a trusting, mutually respectful nurse-client relationship is the initial focus in this particular scenario. To best minimize further trauma, the nurse will provide the client with an explanation of all care (physical contact) that will tak 1 Correct3 Correct5 A young woman is brought to the emergency department by friends after being sexually assaulted. The client has a small but deep laceration on her chin, as well as contusions on her arms and legs. The client appears withdrawn but calm. Place the following nursing interventions in the appropriate order to best address the client’s immediate needs. What action should the nurse manager take when it becomes apparent that communication between the nurse and the client is consistently superficial? 1 Assessing the client’s ability to understand the nurse’s questions "This illness is serious, but with treatment I think I have a chance to get better." "I know I got sick because I’ve been causing a lot of problems at home." Incorrect4 "Now I can’t go to the prom because I have this stupid disease." "I’m going to do my best to fight this awful disease." Correct2 "My smoking pot probably caused the leukemia." Incorrect1 A female adolescent in group therapy tells the other group members that while out on a pass she used marijuana because her boyfriend made her smoke it. What defense mechanism is the client using? 1 Correct3 Projection An older adult with a chronic degenerative disease progresses to the stage at which self-care is no longer possible, and admission to a long-term care facility becomes necessary. What is the major developmental conflict for this client, according to Erikson? Intimacy versus isolation Correct2 Ego integrity versus despair The nurse’s role in maintaining or promoting the health of the older adult should be based on which principle? 1 Some physiologic changes that occur as a result of aging are reversible. Thoughts of impending death are common and depressing to most older adults. 3 Older adults can better accept the dependent state that chronic illness often causes. Correct4 There is a strong correlation between successful retirement and maintaining health. Incorrect2 Undoing Incorrect2 Denial Evaluating how actively the nurse has been listening to the client Correct2 Grief Correct1 Many small plastic bags Correct1 A strong odor of acetone A client with bipolar disorder has been admitted for alcohol detoxification, and laboratory tests are performed. Which results should prompt the nurse to notify the admitting health care provider? Select all that apply. 1 Correct3 5 A nurse begins terminating the consistent one-to-one relationship with a client who is soon to be discharged. How might the nurse expect the client to respond to the termination of their relationship? The home care nurse visits a child in whom failure to thrive has been diagnosed and makes observations that lead the nurse to suspect that the house is being used as a methamphetamine laboratory. Which observations support this conclusion? Select all that apply. Correct2 Correct3 Blood urea nitrogen: 25 mg/dL (9.0 mmol/L Correct6 Serum sodium: 140 mEq/L (140 mmol/L) Lithium level: 1.2 mEq/L (1.2 mmol/L) Incorrect4 Serum albumin: 2.9 g/dL (29 g/L) Prothrombin time: 13.9 seconds Correct2 Hemocrit: 47% Incorrect1 4 Correct5 Jars containing bright-yellow crystals The parents of an autistic child begin family therapy with a nurse therapist. The father states that the family members wish to share their religious beliefs with the therapist. What should the nurse do? Limit the father's discussion of religion. 2 Include the mutual discussion of religious beliefs. 3 Invite the family's religious leader to a therapy session. Correct4 Encourage family discussion of their religion in the sessions. What is the best initial approach to take with a self-accusatory, guilt-ridden client? 1 Contradict the client's persecutory delusions. A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, "Things always seem the same. They never change." The nurse suspects that the client is feeling hopeless. For what indication of hopelessness should the nurse assess the client? Correct1 Outbursts of ange An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis? Accept the client's statements as the client's beliefs Correct2 A pot of tall plants with broad leaves Many empty cold medicine bottles Correct1 Correct3 Correct2 Argues with adults Which client assessment does the nurse determine is inconsistent with the diagnosis of anorexia nervosa, restricting type? Engages in episodes of purging What should the nurse teach parents about childhood depression? Correct1 May appear as acting-out behavior The nurse is interviewing a female adolescent with anorexia nervosa who is malnourished and severely underweight. Which statement leads the nurse to conclude that the client is experiencing secondary gains from her behavior? 1 "I'm as big as a house." 2 "I get straight A's in school." "My mother keeps trying to get me to eat." A client with a long history of alcohol abuse who has been hospitalized for 1 week tells the nurse, "I feel much better and probably won't need any more treatment." What does the nurse conclude when evaluating the client's progress? 1 The client has accepted the illness and now must use willpower to resist alcohol. Correct3 The client's lack of insight into the emotional aspects of the illness indicates the need for continued supervision. The client will probably not use alcohol again as long as the client's family remains supportive. Incorrect2 Easily distracted Incorrect1 Incorrect1 A nurse in a mental health unit of the emergency department of a hospital frequently cares for adolescents who attempt suicide. What is important for the nurse to remember about adolescent suicide behavior? 1 2 Correct4 Boys are more likely to use lethal methods than are girls. A 42-year-old adult with a long history of alcohol abuse seeks help in one of the local hospitals. What does the nurse consider to be the major underlying factor for success in a client’s alcohol treatment program? 1 Family Correct2 Motivation A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa? 1 The client is obese and attempting to lose weight. Correct2 The client behaves appropriately and looks normal. A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the mosteffective treatments for alcoholism? Daily administration of disulfiram 2 Girls talk more about suicide before attempting it. Incorrect3 Girls use more dramatic methods than do boys. Boys account for more attempts than do girls. Incorrect1 3 Correct4 Active membership in Alcoholics Anonymous A severely depressed male client responds to therapy and with the help of the staff begins to set some daily objectives. Which behavior mostindicates improvement in this client? 1 Staying clear of people who make him anxious Correct2 Talking with at least one person on the unit daily A client with recurrent episodes of depression comes to the mental health clinic for a routine follow-up visit. The nurse suspects that the client is at increased risk for suicide. What is a contributing factor to the client's risk for suicide? Psychomotor retardation 2 Decreased physical activity 3 Deliberate thoughtful behavior Correct4 Overwhelming feelings of guilt A client who is to begin a physical therapy regimen after orthopedic surgery expresses anxiety about starting this new therapy. Why does the nurse respond that some of this apprehension can be an asset? 1 Slow physiological function Increase alertness to the environment Correct2 Admission to an alcoholic unit in a hospital Individual or group psychotherapy Incorrect1 Incorrect 1. Dieting is an attempt to maintain control. Incorrect 2. Many clients who call a crisis hotline are extremely anxious. The nurse answering the hotline phone remembers what characteristic as distinguishing posttraumatic stress disorders from other anxiety disorders? 1 Lack of interest in family and others Correct2 Reexperiencing the trauma in dreams and flashbacks A nurse knows that individuals who are alcoholics use alcohol for what reason? Correct1 Blunt reality A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms should the nurse anticipate that this client might use? Projection 2 Repression Correct3 Regression 4 Conversion When the nurse is managing the care of an acutely depressed client, which intervention demonstrates that the nurse recognizes the client's fundamental mental health need? Correct1 Role modeling a hopeful attitude regarding life and the future Anorexia nervosa follows a cyclical pattern. Place the following statements in order of progression through this cycle, with 1 as the first step and 4 as the last step. Sociocultural (fashion, "superwoman" issues, and the diet and fitness industry), biological, psychological, and familial factors all influence the development of anorexia nervosa [1] [2]. Dieting, exercise, purging, and laxatives are used to lose weight, with the resulting primary gain of a feeling of control over one's life. As weight is lost, the individual feels a sense of accomplishment, and self-esteem increases. Finally, secondary gains such as attention from parents and peers reinforce the behaviors associated with anorexia nervosa. When seeking attention from others Incorrect1 Correct5 In what situation should a nurse anticipate that a client will experience a phobic reaction? 2 When thinking about the feared object Correct3 When coming into contact with the feared object During the intake interview at a mental health clinic, a client in withdrawal reveals to the nurse long-term, high-dose cocaine use. Which signs and symptoms support the conclusion that the client has been abusing cocaine for a prolonged time? Select all that apply. Correct1 Sadness Euphoria 3 Loss of appetite 4 Impaired judgment Incorrect2 Secondary gains reinforce the anorectic client's behaviors. Incorrect 3. Sociocultural attitudes exert pressure to attain an idolized body. Incorrect 4. Self-esteem increases as weight is lost. Incorrect1 A client with a history of methamphetamine use is admitted to the mental health unit because of aggressive, violent behavior. For what clinical manifestations of methamphetamine use should the nurse assess this client? Select all that apply. 1 Correct3 Hyperthermia A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member? Correct1 Regression A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiologic characteristic should the nurse include? Periodic exacerbations 2 Aggressive acting-out behavior 3 Hypoxia of selected areas of brain tissue Correct4 Areas of brain destruction called senile plaques Clients with eating disorders often exhibit similar symptoms. What should the nurse expect an adolescent with anorexia nervosa to exhibit? Correct1 Affective instability Tachycardia Correct2 Bradypnea Psychomotor retardation Correct1 Correct1 A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions? Correct1 Mild A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing? Guilt A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing? Guilt A woman with bipolar disorder, manic episode, has been spending thousands of dollars on clothing and makeup. She has been partying in bars every night and rarely sleeps or eats. The nurse in the outpatient clinic knows that this client rarely eats. What does the nurse recognize as the mostlikely cause of her eating problems? 1 Feelings of guilt Need to control others 3 Desire for punishment Correct4 Excessive physical activity A nurse is counseling the spouse of a client who has a history of alcohol abuse. What does the nurse explain is the main reason for drinking alcohol in people with a long history of alcohol abuse? Correct1 Incorrect2 Incorrect1 During a home visit to an older adult, the nurse observes a change in behavior and suspects delirium. The nurse assesses the client for one of several conditions that may have precipitated the delirium. Select all that apply. Correct1 Correct3 5 Restricted mobilit A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? Chronic confusion Correct2 Disordered thinking During an assessment interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing? 1 Insomnia Narcolepsy A nurse in an outpatient mental health setting has been assigned to care for a new client who has been found to have an antisocial personality disorder. What does the nurse expect to observe in the client during the assessment? Correct2 Urine retention Correct4 Dehydration Dementia Incorrect2 Infection They are dependent on it. 1 Correct3 Displays charm, has an above-average intelligence, and tends to manipulate others A nurse working on a substance abuse unit knows that the individual uses opioids most commonly for what reason? 1 Desires independence Correct2 Is trying to reduce stress A nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? Correct1 Strong desire to improve her body image A client proclaims that he is "the second son of God." What type of delusion does the nurse identify? 1 Influence Correct2 Religious A nurse assesses a client recently admitted to an alcohol detoxification unit. What common clinical manifestation should the nurse expect during the initial stage of alcohol detoxification? Correct1 Nausea When visiting hours are over, a nurse approaches a client with paranoid schizophrenia, who shouts, "You're the one that made my lover leave me." What conclusion does the nurse make about the client? Has scars from self-mutilation and a history of many negative relationships Incorrect2 Pays great attention to detail and demonstrates a high level of anxiety Correct1 Correct3 Incorrect3 2 The patient is actively hallucinating. Correct3 The patient feels a sense of vulnerability A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feelings stop." What clinical manifestation is evident? Feelings of panic The nurse is caring for a client with dementia whose expression of emotions is altered. Which behavior is unexpected with this client? 1 Lability 2 Passivity Curiosity An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing? 1 Mild 2 Panic Severe Correct4 Moderate The patient is disoriented. Incorrect1 Correct1 Incorrect1 A young adolescent is found to have anorexia nervosa. What does the nurse understand probably precipitated the anorexia nervosa? 1 2 Correct4 An inaccurate perception of hunger stimuli and a struggle between depende A mental health nurse is working on a unit where many clients have the diagnosis of alcoholism. Which defense mechanism does the nurse identify as most commonly used by clients who are alcoholics? Denial A client being admitted for alcoholism reports having had alcoholic blackouts. What is the best description of an alcoholic blackout? A fugue state resembling absence seizures 2 Fainting spells followed by loss of memory 3 Loss of consciousness lasting less than 10 minutes Correct4 Absence of memory in relation to drinking episodes The nurse is working with a client who has a diagnosis of borderline personality disorder. What personality traits should the nurse expect the client to exhibit? Select all that apply. Correct1 Engaging The inability to deal with being the center of attention in the family and a desire for independence Incorrect3 An unconscious wish to punish a parent who tries to dominate the adolescent's life The acting out of aggressive impulses, resulting in feelings of hopelessness Correct1 Correct4 Correct6 2 5 Perfectionisti A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. Significant life stress 2 Severe anxiety 3 Generalized pain Excessive caffeine 5 Chronic depression Environmental noise/distracto The nurse can identify the mostcommonly demonstrated comorbid disorders associated with generalized anxiety disorder (GAD) by assessing the client for which of the following? Select all that apply. 1 Obesity Manipulative Correct4 Withdrawn Incorrect3 Indecisive Correct5 Correct3 Suicidal ideations 4 Impaired cognitive function Signs of alcohol withdrawa A recovering alcoholic joins Alcoholics Anonymous (AA) to help maintain sobriety. What type of group is AA? 1 Social group Correct2 Self-help group The nurse is interviewing the family about the onset of problems in a young client with the diagnosis of schizophrenia. In what stage of development does the nurse expect that the client's difficulties with reality testing began? 1 Puberty Correct2 Adolescenc An assistant to a dean at a local university is admitted to the psychiatric inpatient unit for assessment and treatment. The client claims to be president of the university. What type of delusion does the nurse identify? 1 Somatic Correct2 Grandiose Phobias Correct2 Correct3 Incorrect1 A client with a recent history of binge eating and purging is admitted to the eating disorder unit with a diagnosis of bulimia nervosa. How does the nurse explain bulimia nervosa to the family? 1 3 Mood swings, ranging from euphoria to depression, associated with food Correct4 Uncontrollable ingestion of large quantities of food in a short period with subsequent purging A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit? 1 Crying 2 Self-mutilation Immobile posturing A nurse who plans to care for a client with an obsessive-compulsive disorder should understand that the client’s personality can usually be characterized in what way? Marked emotional maturity 2 Rapid, frequent mood swings 3 Elaborate delusional systems Correct4 Doubts, fears, and indecisiveness A nurse knows that individuals who are alcoholics use alcohol for what reason? Refusal to eat in public accompanied by excessive private overeating Incorrect2 Uncontrollable pilfering and hoarding of food for later consumption Correct1 Incorrect3 Correct1 Blunt reality A nurse is counseling the spouse of a client who has a history of alcohol abuse. What does the nurse explain is the main reason for drinking alcohol in people with a long history of alcohol abuse? They are dependent on it. When caring for clients who are demonstrating manic behavior, the nurse must constantly reassess these clients' physical needs. What characteristic about these clients makes this particularly important? 1 Will withdraw to their rooms if left alone 2 Have difficulty making their needs known May gain too much weight from overeating Correct4 May become exhausted from excessive activity A client tells the nurse, "All my friends experiment with drugs. I like the high I get when I huff paint. Nothing bad is going to happen to me." What is the best response by the nurse? 1 "Inhalants can cause a mild state of intoxication." Correct2 "Huffing paint can damage your lungs, kidneys, and liver A client who is a regular user of cocaine is admitted to a rehabilitation facility. Which common side effects of regular cocaine use should the nurse expect when assessing this client? 1 Nausea, fatigue, and extreme hunger Correct2 Incorrect3 A client is admitted to the hospital with a diagnosis of depression. What clinical manifestations of depression does the nurse expect when assessing this client? 1 2 What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants? 1 Drowsiness Correct2 Seizure activity A nurse is interviewing a child with attention deficit disorder. For which major characteristic should the nurse assess this child? Correct1 Overreaction to stimuli A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When the client sets outcomes, what need is it important for him to understand? 1 Plan to avoid people who drink. 2 Accept that he is a fragile person. Develop new social drinking skills. Correct4 Restructure his life without alcohol. Psychomotor retardation Correct3 Suspicion of others Flight of ideas Anxiety, dysphoria, and extreme suspicion Incorrect1 A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? Select all that apply. 1 3 Correct5 Addresses how the addiction has contributed to family distress Many clients who call a crisis hotline are extremely anxious. The nurse answering the hotline phone remembers what characteristic as distinguishing posttraumatic stress disorders from other anxiety disorders? 1 Lack of interest in family and others Correct2 Reexperiencing the trauma in dreams and flashbacks A client with recurrent episodes of depression comes to the mental health clinic for a routine follow-up visit. The nurse suspects that the client is at increased risk for suicide. What is a contributing factor to the client's risk for suicide? Psychomotor retardation 2 Decreased physical activity 3 Deliberate thoughtful behavior Acknowledges the effects of the addiction on the family Correct4 Expresses uncertainty about meeting with the nurse Verbalizes difficulty identifying personal strengths Correct2 Describes how others have caused the addiction Incorrect3 Correct1 Correct4 Correct4 Overwhelming feelings of guilt A client with schizophrenia is admitted to an acute care psychiatric unit. Which clinical findings indicate positive signs and symptoms of schizophrenia? 1 Withdrawal, poverty of speech, inattentiveness 2 Flat affect, decreased spontaneity, asocial behavior Hypomania, labile mood swings, episodes of euphoria Correct4 Hyperactivity, auditory hallucinations, loose associations A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing? Guilt What should a nurse conclude that a client is doing when he makes up stories to fill in blank spaces of memory? 1 Lying 2 Denying 3 Rationalizing Confabulating A client with a history of alcohol abuse says to the nurse, "Drinking is a way out of my depression." Which strategy will probably be most effective for the client at this time? Incorrect3 Incorrect3 Correct1 A self-help group A person with a history of alcoholism says, "I've been drinking since last Friday to celebrate my son's graduation from college." What defense mechanism does the nurse identify? 1 Denial 2 Projection Identification Correct4 Rationalization hat characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa? 1 Controlling 2 Empathetic Focused on food Correct4 Based on realistic limits A nurse is interviewing a client newly admitted to an outpatient program after withdrawal from alcohol. What behavior best indicates that the client has accepted that drinking is a problem? 1 Participates in scheduled counseling sessions Attends Alcoholics Anonymous meetings daily Correct2 A client who was admitted to the psychiatric unit because of a major depressive disorder is exhibiting increasingly withdrawn behavior. The nurse understands that eventually the client will experience what feelings? 1 A nurse in a mental health unit of the emergency department of a hospital frequently cares for adolescents who attempt suicide. What is important for the nurse to remember about adolescent suicide behavior? 1 3 Girls talk more about suicide before attempting it. Correct4 Boys are more likely to use lethal methods than are girls. A recovering alcoholic joins Alcoholics Anonymous (AA) to help maintain sobriety. What type of group is AA? 1 Social group Self-help grou A 56-year-old man is admitted to the inpatient unit after family members report that he seems to be experiencing auditory hallucinations. The man has a history of schizophrenia and has had several previous admissions. Which statement indicates to the nurse that the client is experiencing auditory hallucinations? 1 "Get these horrible snakes out of my room!" Correct2 Correct2 Girls use more dramatic methods than do boys. Incorrect2 Boys account for more attempts than do girls. Isolation Correct2 Hedonia Incorrect1 Incorrect 1. Dieting is an attempt to maintain control. Incorrect 2. Self-esteem increases as weight is lost. Incorrect 3. Sociocultural attitudes exert pressure to attain an idolized body. Correct 4. Secondary gains reinforce the anorectic client's behaviors. "I am not the devil! Stop calling me those names!" A client with a long history of alcohol abuse who has been hospitalized for 1 week tells the nurse, "I feel much better and probably won't need any more treatment." What does the nurse conclude when evaluating the client's progress? The client has accepted the illness and now must use willpower to resist alcohol. 2 Correct3 Anorexia nervosa follows a cyclical pattern. Place the following statements in order of progression through this cycle, with 1 as the first step and 4 as the last step. A client who is a polysubstance abuser is mandated to seek drug and alcohol counseling. What is an appropriate initial outcome criterion for this client? Correct1 Verbalizes that a substance abuse problem exists While a nurse is assisting with morning care for a client with the diagnosis of schizophrenia, the client suddenly throws off the covers and starts shouting, "My body is disintegrating! I'm being pinched." What term best describes the client's behavior? Correct1 Somatic delusion The client's lack of insight into the emotional aspects of the illness indicates the need for continued supervision. The client will probably not use alcohol again as long as the client's family remains supportive. A desire to control her life Correct1 Correct3 A 5-foot 5-inch (165 cm) 15-year-old girl who weighs 80 lb (36.3 kg) is admitted to a mental health facility with a diagnosis of anorexia nervosa. The nurse recognizes what factor as the most likely cause of her problem? A client with schizophrenia is admitted to an acute care psychiatric unit. Which clinical findings indicate positive signs and symptoms of schizophrenia? 1 3 Hypomania, labile mood swings, episodes of euphoria Correct4 Hyperactivity, auditory hallucinations, loose associations Nursing care for a client with a bipolar mood disorder, manic episode, is sometimes difficult. What important fact about these clients should the nurse consider when planning their care? 1 Embarrassed by their behavior Correct2 Aware of their environment and reality AWhat characteristic of an adolescent girl suggests to the nurse that she has bulimia? 1 History of gastritis 2 Positive self-concept Excessively stained teeth or success in a client’s alcohol treatment program? Flat affect, decreased spontaneity, asocial behavior Incorrect2 Withdrawal, poverty of speech, inattentiveness Incorrect1 Correct3 Correct3 Correct2 Motivatio What is the greatest difficulty for nurses caring for the severely depressed client? Client's lack of energy 2 Negative cognitive processes 3 Client's psychomotor retardation Correct4 Contagious quality of depression It is determined that a staff nurse has a drug abuse problem. What approach to the staff nurse’s addiction should be taken as an initial intervention? 1 Counseled by the staf f psychiatrist 2 Dismissed from the job immediately Referred to the employee assistance program An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. What specific outcome criterion is unique to adolescents with this problem? 1 Increased impulse control 2 Identification of two positive personal attributes Demonstration of respect for the rights of others Family Incorrect1 A severely depressed male client responds to therapy and with the help of the staff begins to set some daily objectives. Which behavior mostindicates improvement in this client? 1 Correct2 Talking with at least one person on the unit daily What is a priority nursing intervention in the care of a drug-dependent mother and infant? Correct1 Supporting the mother's positive responses toward her infant When planning care for a client who has just completed withdrawal from multipledrug abuse, what reality in relation to the client should the nurse take into consideration? 1 Unable to give up drugs Unconcerned with reality Correct3 Unable to delay gratification What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol? Correct1 Motivational readiness it with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit? 1 Slow pulse, mild weight loss, and alopecia 2 Compulsive behaviors, excessive fears, and nausea Incorrect2 Staying clear of people who make him anxious Correct3 An executive assistant experiences an overwhelming impulse to count and arrange the rubber bands and paper clips in his desk. The client feels that something dreadful will occur if the ritual is not carried out. Considering the client's symptoms, what does the nurse conclude about the rituals? 1 They are useful in our society as long as they can be controlled Correct2 They serve to control anxiety resulting from unconscious impulses A client who uses ritualistic behavior taps other clients on the shoulders three times as part of the ritual. What does the nurse infer about this client? 1 A blurred personal identity Poor control of sudden urges 3 A disturbance in spatial boundaries Correct4 A diminished ability to adapt to life's stresses On the third day of hospitalization, a client with a history of heavy drinking begins experiencing delirium alcohol withdrawal syndrome. What is the mostappropriate response by the nurse when the client begins experiencing hallucinations? 1 Withholding intervention, because the client may be having vivid dreams 2 Asking the client to describe the hallucinations and explaining that they are not real Administering the prescribed medication to the client to subdue the agitated be Incorrect2 Amenorrhea, excessive weight loss, and abdominal distention Correct3 Correct3 Incorrect1 A nurse in the mental health unit is working with a group of adolescent girls with the diagnosis of anorexia nervosa. What does the nurse recall is the major health complication associated with intractable anorexia nervosa? 1 2 A client arrives at the mental health clinic complaining about feelings of extreme terror when attempting to ride in an elevator and feelings of uneasiness in large crowds. He reports that these fears are interfering with his concentration at work. What does the nurse identify as the source of these symptoms? 1 Conflict with society, resulting in an obsession 2 Depression about life events, resulting in unreasonable fears Generalized anxiety about conflicts, resulting in unreasonable fear nurse is caring for a client exhibiting compulsive behaviors. The nurse concludes that the compulsive behavior usually incorporates the use of which defense mechanism? Projection 2 Regression Correct3 Displacement 4 Rationalizatio Cardiac dysrhythmias resulting in cardiac arrest Correct3 Decreased metabolism causing cold intolerance Endocrine imbalance causing amenorrhea Incorrect3 Incorrect1 What is the prognosis for a normal, productive life for a child with autism? 1 2 Correct4 Unlikely because of interference with so many parameters of function unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing? 1 Fixed delusion 2 Magical thought Pathological regression Correct4 Command hallucinatio A nurse is making an assessment of a client's hallucinatory behavior. What is the most common type of hallucination? Visual 2 Tactile Correct3 Auditory Ensured as long as the child attends a school tailored to meet needs Incorrect3 Often related to the child's overall temperament Dependent on an early diagnosis Withdrawing from friends Correct1 Incorrect1 Incorrect1 nd grief counselors have been working with fellow students. What behaviors indicate to the school nurse that another student may be considering suicide? Select all that apply. Correct2 Giving away prized possessions What are the "four As" for which nurses should assess clients with suspected Alzheimer disease? Correct1 Amnesia, apraxia, agnosia, aphasia A newly admitted client is apathetic and exhibits an inappropriate affect. A diagnosis of schizophrenia is made. In light of the diagnosis, what is one symptom the nurse expects to identify in the client's communication or behavior? Logical deductions 2 Suicidal preoccupation 3 Absence of self-criticism Correct4 Response to internal stimulation A client with a history of gambling is experiencing legal difficulties for embezzling money and has been required to obtain counseling. During an intake interview the client says, "I never would have done this if I'd been paid what I am worth." What factor will create the greatest difficulty in helping this client develop insight? Feelings of boredom and emptiness 2 Grandiosity related to personal abilities Correct3 Correct3 Projection of reasons for difficulties onto others An anxious client reports experiencing pain in the abdomen and feeling empty and hollow. A diagnostic workup reveals no physical causes of these clinical findings. What term best reflects what the client is experiencing? 1 Dissociation Correct2 Somatization A client is admitted to the mental health unit with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit? 1 Slow pulse, mild weight loss, and alopecia 2 Compulsive behaviors, excessive fears, and nausea Amenorrhea, excessive weight loss, and abdominal distention What is a primary consideration for the nurse caring for a client with a history of substance abuse? Correct1 Setting firm, consistent limits and not varying from them client who has a long history of alcoholism has not worked for the past 10 years. When the nurse asks about daily activities the client responds, "I currently work in the office of a local construction company." Which mental mechanism should the nurse suspect that the client is using? 1 Regression Sublimation 3 Incorrect2 Correct1 Incorrect1 Incorrect1 Compensation Correct4 Confabulatio An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. What does the nurse identify as the cause of these problems? Receptive aphasia A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Which data are the cause of the nurse's concern? Select all that apply. Correct1 Tremors in both hands make it difficult for the client to hold a cup. A client experiencing nonspecific, excessive, unpleasant feelings of being worried concerning one's safety likely is experiencing which mental health disorder? Phobia 2 Panic disorder Correct3 Generalized anxiety disorder (GAD A mother brings her 5-year-old daughter to the children's clinic after teachers report that the girl is disobedient and hostile. The child has a negative attitude and argues often with her teachers. At this time she has not violated the rights of other students. The mother reports that she has also noticed this behavior at home. The nurse suspects that the behavior described is associated with what disorder? Anxiety disorder 2 Conduct disorder Correct3 Correct1 Incorrect1 Correct1 3 Correct4 Oppositional defiant disorder On the third day of hospitalization, a client with a history of heavy drinking begins experiencing delirium alcohol withdrawal syndrome. What is the mostappropriate response by the nurse when the client begins experiencing hallucinations? 1 Withholding intervention, because the client may be having vivid dreams 2 Asking the client to describe the hallucinations and explaining that they are not real Administering the prescribed medication to the client to subdue the agitated behavior A 20-year-old homeless client at 38 weeks' gestation visits the prenatal clinic for the first time. She is accompanied by her 21-year-old boyfriend, who is the father of the baby. The nurse becomes concerned because as they sit in the waiting room, they are sneezing and yawning and have teary eyes. With what substance are these withdrawal signs associated? Heroin For what most common characteristic of autism should a nurse assess a child in whom the disorder is suspected? Responds to any stimulus 2 Responds to physical contact Correct3 Unresponsiveness to the environment nurse collaborates with a depressed client to increase self-esteem. What behavior should the nurse recall as typical of this type of client? Major depressive disorder "You’re frightened. Come with me to your room, and we can talk about it Correct1 Encouraging the client to practice self-control Incorrect1 Avoiding helping the client make connections between anxiety-producing situations and hallucinations Incorrect3 Distracting the client’s attention by providing a competing stimulus that is stronger than the hallucinations One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client begs, "Please let me go. I trust you. The Mafia is going to kill me tonight." Which response is mosttherapeutic? A nurse is counseling a client who is experiencing substance abuse delirium. What communication strategies should be used by the nurse when working with this client? 2 Using humor when communicating with the client Correct3 Offering an introduction to the client at each me A client is experiencing hallucinations. What therapeutic intervention should the nurse plan to help the client cope with the hallucinations? 1 Reinforcing the perceptual distortions until the client develops new defenses 2 Providing an unstructured environment and assigning the client to a private room Correct4 What response from the nurse demonstrates an understanding of hallucinating behavior by a client? Correct1 Asking, "What are the voices telling you to do?" Sets unrealistic goals Have a lunch tray sent to the client’s room. Incorrect1 Correct1 Incorrect1 On the fifth day of hospitalization the nurse notes that a depressed client remains lying on the bed when the clients are called to the dining room for lunch. What should the nurse do to encourage the client to eat? Correct2 Offer to accompany the client to the dining room. he nurse is caring for a client with a somatoform disorder, conversion-type paralysis. What is the best nursing approach? Discussing topics other than the paralysis A nurse is assessing several depressed clients. Which behavior should alert the nurse to closely monitor a client for a suicide attempt? When the client does not eat Correct2 If the client describes a plan for suicid fter detoxification a client with a long history of alcohol abuse decides to attend Alcoholics Anonymous (AA) meetings at the hospital. On the day of the second meeting the client says, "I can’t go to the AA meeting today because I’m expecting an important phone call." What is the mosttherapeutic response by the nurse? Correct1 "You are expected to go to the meeting." A nursing home resident with dementia of the Alzheimer type, stage 2, who has been receiving donepezil is engaging in numerous acting-out behaviors. On what should the nurse base the initial plan of care? 1 Assessing the client’s level of consciousness Identifying the stressors that precipitate the client’s behavior A paranoid client is scheduled to begin group therapy. The client refuses to attend. What should the nurse do next? Correct2 Incorrect1 "Help your child find new friends and encourage finding a job and assuming personal responsibility." Correct1 Correct1 Correct1 Accept the client’s decision without discussion. An adolescent client with antisocial personality disorder plans to live with the parents after discharge. The parents request advice on how to respond to their child’s unruly behavior. What is the most therapeutic response by the nurse? "Discuss the behavior with your child and encourage the development of self-control." 2 "Avoid setting expectations for behavior and react to each situation as it arises." 3 Correct4 "Set clear limits, explain the consequences if your child disregards them, and firm In an outpatient mental health clinic a nurse is working with a client who is beginning to address more effective ways to handle stressful situations. The best nursing action to include in the plan of care is to have the client do what? Identify unhealthy habits that need to be altered. ewly diagnosed schizophrenia. What factor in the client’s history indicates a greater potential for recovery? Vague prepsychotic symptoms Ten minutes before lunch, a client with obsessive-compulsive behavior begins the ritual of changing clothes for the fourth time. How should the nurse respond to this behavior? Correct1 What should a nurse consider when planning care for a client who is using ritualistic behavior? Tell the client to finish changing clothes and say that lunch can be eaten afterward. Incorrect1 1 2 Correct4 The repeated thought or act A depressed client cries when the family does not visit. What is the mosttherapeutic response by the nurse? 1 "It’s difficult to realize that no one cares about you." Correct2 "Your family didn’t visit, and now you’re feeling rejected." A client comes to the mental health clinic for treatment of a phobia of large dogs. What should the nurse anticipate that this client will demonstrate? Correct1 Fear of discussing the phobia Resentmen A disturbed client says, "The voices are saying that I killed my husband." What is the best response by the nurse? "I just saw your husband, and he’s doing fine." 2 "Tell me more about your concerns for your husband." 3 "We’ll put you in a private room where you’ll be safe." Correct4 Incorrect2 Clients do not want to repeat their rituals but feel compelled to do so. The nurse should try to stop the ritual immediately after it is started. Incorrect3 Clients need to realize that ritualistic behavior serves no purpose. The nurse must try to limit the ritualistic behavior. Incorrect1 "You seem to be having very frightening thoughts right now." A client with the diagnosis of borderline personality disorder is manipulative and uses this behavior to get cigarettes from other clients. One day the client begins to badger another client. What should the nurse say while removing the client from the area? Correct1 "You must leave people alone; this behavior is unacceptable." A client with borderline personality disorder receives the wrong tray for lunch and scolds the dietary staff regarding this mistake. What is the most appropriate response by the nurse? "Getting angry is inappropriate; your behavior must stop." 2 "Yelling is unacceptable and will only get you placed in seclusion." 3 "You have to eat the first tray of food; then I’ll get another tray for you." Correct4 "It must be frustrating to get the wrong tray. I’ll order another tray for you." One day while shaving, a male client with the diagnosis of bipolar disorder tells the nurse, "I’ve hidden a razor blade, and tonight I’m going to kill myself." What is the best reply by the nurse? Correct1 "You’re going to kill yourself? A 17-year-old client is admitted to the hospital because of weight loss and malnutrition, and the primary healthcare provider diagnoses anorexia nervosa. After the client’s physical condition is stabilized, the provider, in conjunction with the client and parents, institutes a behavior-modification program. What component of behavior modification verbalized by parents leads the nurse to conclude that the parent has an understanding of the therapy? Correct1 Rewarding positive behavior Probate judge Incorrect1 Client’s family Client’s psychiatrist Law enforcement officer "Try not to be afraid. I won’t hurt you." Incorrect1 "I’m not one of them—I’m here to help you." "Your family and the staff are trying to help you." "I can see that you’re upset. We can talk more later." An adult client with schizophrenia is involuntarily admitted to the psychiatric unit. While off the unit for needed testing, the client runs away. Legally, who should the nurse notify immediately? 2 3 Correct4 A nurse is planning activities for a withdrawn client who is hallucinating. What is the most therapeutic activity for this client? A client with schizophrenia, paranoid type, is readmitted to the hospital at the insistence of the family. While exploring feelings about the readmission, the client angrily shouts, "You’re one of them! Leave me alone!" How should the nurse respond? 2 3 Correct4 A 54-year-old has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After the person is found disoriented and semi-naked while walking down a street, the diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety upon admission to a long-term care facility. What is the best nursing intervention in light of the client’s diagnosis? Going for a walk with the nurse Correct1 Incorrect1 Correct1 Correct2 Reassuring the client with the frequent presence of staf f members A nurse is assessing a client with bulimia nervosa. What should the nurse ask to obtain information about the client’s intake habits and patterns? 1 "Are you trying to control other people through the use of food?" "When you socialize, do you find that you eat more than when you eat by yourself?" 3 "Do you find yourself eating more right before the beginning of your menstrual cycle?" Correct4 "How frequently are you eating in A depressed older client has not been eating well since her admission to the hospital. The client repeatedly states, "No one cares." What is the mostappropriate response by the nurse? "We all care about you; now please eat." 2 "We all care about you; you have to eat to stay alive." Correct3 "I care about you. What are some foo A client comes to the hospital because of intense feelings of unrest, inability to sleep, and frequent episodes of panic. The client tells the nurse, "I admitted myself because I think I’m going crazy." What does the nurse identify the client’s remark to be? A plea for suppo An adolescent client with an antisocial personality disorder has been admitted to the hospital because of drug abuse and repeated sexual acting-out behavior. Which Incorrect2 Exploring the reasons for the concerns Incorrect1 Promises never to take drugs again Incorrect1 Discusses the need to seduce other adolescents Recognizes the need to conform to society’s norms Identifies the feelings underlying the Questioning the client about plans for the future Incorrect1 Inquiring whether the client is now considering s client behavior supports the nurse’s conclusion that actions directed toward modifying the behavior of this client have been successful? 2 3 Correct4 hat should the nurse keep in mind about rituals when planning care for a client who uses ritualistic behavior? Correct1 nurse plans to evaluate a newly admitted depressed client’s potential for suicide. What is the best approach to obtaining this information? Correct2 hyperactive 9-year-old child with a history of attention deficit–hyperactivity disorder is admitted for observation after a motor vehicle collision. On what should nursing actions be focused when the nurse is teaching about personal safety? 2 Correct3 A client with a history of obsessive-compulsive behaviors has a marked decrease in symptoms and expresses a wish to obtain a part-time job. On the day of a job Talking with the child about the importance of using a seat belt Asking the child to verbalize as many safety rules as possible Requesting that the child write at least three safety rules Incorrect1 They help the client control anxie "I know you’re anxious, but by forcing yourself to go to the interview you may conquer your fear." Incorrect1 "If going to an interview makes you this anxious, you’re probably not ready to go back to work." "It must be that you really don’t want that job after all. I think you should reconsider going to the interview." "Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there." interview the client arrives at the mental health center with signs of anxiety. What is the most therapeutic response to the client’s behavior by the nurse? 2 3 Correct4 college health clinic reporting increasing anxiety, loss of appetite, and an inability to concentrate. What is the most therapeutic response by the nurse? 2 "What have you identified as the cause of your anxiety?" Correct3 "It’s been difficult for you. How long has this been going on?" 4 "Let’s talk about your problems. Are you having difficulty client has been on the psychiatric unit for several days. The client arouses anxiety and