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,A client who has successfully adjusted to a colostomy A social phobia
declines the invitation to speak to a support group on the
subject of alteration in body image; the client reports an
extreme fear of public speaking. The nurse analyzes this
information & determines that the client's fear would be
considered which diagnosis?
The nurse is preparing for the hospital discharge of a "I can call my therapist when I'm hallucinating so I can talk about my feelings &
client with a history of command hallucinations to harm plans & not hurt anyone."
self or others. The nurse instructs the client about
interventions for hallucinations & anxiety & determines
that the client understands the interventions when the
client states which?
A client has been brought to the ER after attempting to Examine the neck area & assess the airway
commit suicide by hanging. The nurse should take which
nursing action first?
A client comes to the clinic after losing all of his personal The client will stop blaming himself for the lack of insurance
belongings in a hurricane. The nurse notes that the client
is coping ineffectively. Which is the least realistic goal for
this client?
The RN has written an outcome statement of "Client will - Stay with the client
feel less anxious by the end of session" for a client with
generalized anxiety disorder. Which interventions should - Administer anxiolytics medications if prescribed.
the LPN use to assist this client in meeting this goal?
Select all that apply. - Ensure the client is in an environment with little stimuli.
The nurse is reviewing the record of a client admitted to The client has the right to demand & obtain release from the hospital
the mental health unit & notes that the client was
admitted by voluntary status. The nurse makes which
determination?
A client with a diagnosis of a recurrent major depression, Altered thought process
exhibiting psychotic features, is admitted to the mental
health unit. In an attempt to create a safe environment for
the client, the nurse designs a plan of care that deals
specifically with which aspect of the client's disorder?
The nurse is assigned to care for a client experiencing Opened ended questions & silence
disturbed thought processes. The nurse is told that the
client believes that the food is being poisoned. Which
communication technique should the nurse plan to use to
encourage the client to eat?
A client who excessively uses alcohol and who is Disulfiram (Antabuse)
motivated to stop tells the nurse, "I know that there is a
medication that can help people like me quit drinking."
Which medication should the nurse explain is available
for this purpose?
, The client diagnosed with paranoid schizophrenia has Provide for safety by recognizing the level of client anxiety and setting limits.
been exceedingly agitated, is threatening & shouting at
everyone, & is refusing to participate in therapy. The nurse
takes which initial action?
The nurse enters a client's room, & the client immediately Contact the HCP
demands to be released from the hospital. On review of
the client's record, the nurse notes that the client was
admitted 2 days ago for treatment of an anxiety disorder
& that the admission was a voluntary admission. The nurse
reports the findings to the RN & expects that the RN will
take which action?
A client with a diagnosis of anorexia nervosa, who is in a A client receiving diagnostic tests
state of starvation, is in a 2 bed hospital room. A newly
admitted client will be assigned to this client's room.
Which client should be an appropriate choice as this
client's roommate?
A client who is diagnosed with pedophilia & recently has "You understand that people fear for their children, but you're feeling unfairly
been paroled as a sex offender says, "I'm in treatment & I treated?"
have served my time. Now this group has posters all over
the neighborhood with my photograph & details of my
crime." Which is an appropriate response by the nurse?
Which data indicates to the nurse that a client may be Constantly neglects personal grooming
experiencing ineffective coping following the loss of her
spouse?
The nurse is collecting data on a client who is actively "Sometimes people hear things or voices others can't hear."
hallucinating. Which nursing statement should be
therapeutic at this time?
The nurse is caring for a client who was recently admitted Interrupt the client & take her for a walk
for anorexia nervosa. Upon entering the client's room, the
nurse finds the client in the middle of a series of sets of
rapid sit-ups. Which action should the nurse take?
A visitor brings a suicidal client a brightly packaged gift. Have the client open the gift with the nurse present
The nurse accompanies the visitor to the client's room &
takes which action?
The nurse is preparing a care plan for the client with Goals & objectives
OCD. The nurse should focus on which as the primary
means to accomplish work with this client?
A client comes to the ER following an assault & is Remain with the client until the anxiety decreases
extremely agitated, trembling, & hyperventilating. Which
initial nursing action is appropriate?