Pt: "The FBI wants to kill me."Ns: I understand that you believe this is true, but i personally find it hard to accept."Voicing doubt; TherapeuticNs. Asst: " Mr J. always calls me sweetie pie. I get so angry when he does that."Ns: " Perhaps you should consider how he is feeling."Belittling feeling; Non therapeuticPt: "my daddy always tucked me into bed at night."Ns: "I'd like to talk more about your relationship with your father."Focusing; therapeuticNs to Pt: "Good morning, Sue. I see you are wearing the hair bow you made in OT."Giving recognition; TherapeuticPt: "I didn't really mean it when I said I wanted to die."Ns: "what makes you say those kinds of things?"Indicating external source of power; non-therapeuticPt: "Do you think I should get a divorce?"Ns: What do you think would be best for you?"Reflecting; therapeuticPt: "Whenever I ask for a different therapy, my doctor just ignores me!"Ns: "I'm sure he knows what is best for you."Defending; Non-therapeuticPt: "We always had so much fun on holidays when I was growing up."Ns: "tell me more about what it was like when you were a little girl."Exploring-TherapeuticPt: (mute. refusing to talk)Ns: "It must have been a horrible experience for you being the only survivor of the automobile accident."Verbalizing the implied; therapeuticPt: " I don't think my life will ever be the same again."Ns: "Cheer up. Everything is going to be okay."Giving reassurance-non therapeuticPt:"I feel like such a failure in the eyes of my family."Ns: "You feel as though you have let your family down."Restating-therapeuticPt: "Do you think I should leave home and get an apartment on my own?"Ns: "I think you would be much better off away from your parents."giving advice-non therapeuticPt: "Good morning, nurse."Ns: "Good morning, Patricia. What would you like to talk about today?"Giving broad opening-Thearpeutic

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Pt: "I'd like to talk about my relationship with my boyfriend Jack."Ns: "Oh, let's don't talk about that. You talk about that too much."Rejecting-non therapeuticPt: "I want to call my husband."Ns: "Why do you want to talk to him after the way he treated you?"requesting an explanation- non therapeuticmechanism of action of antidepressant medicationstargets neurotransmitters NE and serotonin. Blocks re uptake which increases levels.What should the nurse be on alert for a client who is on antidepressants?-sudden increase in energy/activity and suicide riskWhen would you expect the client to begin showing signs of relief after antidepressant therapy?1-4 weeksexample of a tricyclic anti-depressantTofranil, Anafarilexample of an MAOINardil, Parnate, Marplanexample of an SSRIZoloft, Prozac, Celexa, Lexapro, Paxil,Luvox, Symbyaxcommon side effects and nursing implications for tricyclic antidepressants-orthostatic hypotension, anti-cholinergic s/e-increase fluid, fiber, sugar free candymost potentially life-threatening adverse effects of MAOIs; symptoms to be on the alert for-hypertensive crisis-headache, NVD-3rd lineLithium carbonate is commonly prescribed for?Bipolar disorderMany times when these individuals are started on lithium therapy, the physician also orders an antipsychotic medication. why?antipsychotic causes immediate effectTherapeutic range and signs and symptoms of lithium toxicity.6-1.5>1.5 is toxic; blurred vision, ataxia, slurred speech, confusion, NVDnursing implications for client on lithium therapy

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give with food and enough sodium and fluidmechanism of action for anxiolyticsCNS depression, immediate actionmost commonly used group of anxiolyticsbenzodiazipenewhat must the client on long-term anxiolytic therapy be instructed about to prevent a potentially life-threatening situation?addiction & tolerance; don't stop suddenly , leads to seizuremechanism of action for antipsychoticstargets neurotransmitter dopamineexamples of older "typical" antipsychoticsThorazine, Haldolexamples of newer "atypical" antipsychoticsClozaril, Abilifypotential adverse hormonal effects associated with antipsychotic medsgynamasteria, decreased libido, hyperprolacteria, amenorrhea, weight gainSymptoms of agranulocytosisfever, malaise, and sore throatsymptoms for NMS (neuroleptic malignant syndrome)high fever, muscle rigidity, tachycardiasymptoms of EPSacathesia, restlessness, distonia, pseudo Parkinson'smedication prescribed for EPSbenzatropine-Cogentin, progentin, benedryllife threatening situation that could occur if client abruptly withdrawals from long term use of CNS stimulantssevere depression with thoughts of suicideNurse Jones does not approve of Pam' s gay lifestyle but accepts her unconditionally nonethelessRespectNurse jones and Pam develop an immediate mutual regard for each otherrapportPam knows that Nurse Jones is always honest with her and will tell her the truth even if it is sometimes painfulgenuineness

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Pam knows that Nurse Jones will not tell anyone else about what they discuss in therapytrustwhen pam talks about her problems, Nurse Jones listens objectively and encourages Pam to reflect on her feelings about the situationEmpathyPam and nurse set goals for their time together.Orientation (Introductory) phaseNurse reads Pam's previous medical recordspre-interaction phaseHaving identified Pam's problem, they discuss aspects for possible change and ways to accomplish themWorking phaseThey establish a mutual contract for interventionOrientation (Introductory) PhaseThe established goals have been mettermination phaseNurse explores her feelings about working with a gay personpre-interaction phasePam weighs the benefits and consequences of various alternatives to changeworking phasepam and nurse discuss a plan of action for pam to employ in the advent of stressful situations following therapytermination phasepam cries and says she cannot stop coming to therapytermination phaseNurse gives Pam positive feedback for attempting to make adaptive changes in her lifewoking phasemary stole some makeup off of the shelf at the storeIdMary began to feel very guilty for taking the makeup after she got home with itsuperegomary took the makeup back to the store and apologized to the clerk for taking itEgo

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2 year old sandy has a temper tantrum when her mother takes a dangerous toy away from herIdsandy sucks on her thumb for comfortIdfrankie wants to do well on her algebra test and stays home to study instead of going out with his friendsEgoFrankie does not do as well on the algebra test as he had hoped. he becomes despondent and refuses to come out of his roomsuper egojack joins his friends when they invite him to drink beer and smoke marijuana with themIdafter having a few beers, jack decides not to drive his car home.EgoJack tells his parents he is sorry for drinking and smokingsuper eo"I don't like people. I'd rather be alone."Isolation"get away from me with that medicine. I know you are trying to poison me!"Mistrust"I feel good about my life. I have alot to be thankful for."Ego integrityFive-year old girl believes she is the cause of her parents divorceguilt" Sure, I'll loan you $10 until your next pay day."Trust"I don't know what to do with my life. College? work? What kind of job would I get anyway?"Role confusion"Mommy! Mommy! I made all A's on my report card!"industry"I'll have to ask my husband. He's the decision maker in our family."Shame and Doubt

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"When I graduate from college I want to work with handicapped children."identity"I plan to work as hard as necessary to help women achieve equality. I plan to see this happen before I die."IntimacyCommon side effects of anxiolyticsdrowsiness, ataxia, mental slowing, confusion"I hate this place. No one cares what i do anyway. It's just a way to bring home a paycheck."Stagnation"Look Mom! I ironed this blouse all by myself."Autonomy"if only I could live my life over again. I'd do things so much differently. I feel like a nothing."DespairI could never be a nurse. I'm not smart enough."Inferiority"Yes, I will be the chairperson for the cancer drive."Initiative"I have been the Girl Scout leader for troop 259 for 7 years now."Generativity

OriginalAlphabetical

KantianismEthical theory by which decisions are based on a sense of dutyLibelWriting false and malicious information about a personBatteryThe un-consented touching of another personCriminal LawProvides protection from conduct deemed injurious to the public welfareNonmaleficenceAbstaining from negative acts toward another, including acting carefully to avoid harm

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AssaultAn act that results in a person's genuine fear and apprehension that he or she will be touched without consentNatural LawThe theory on which decisions are based in which evil acts are never condoned, even if they are intended to advance the noblest of endsTortsA violation of a civil law in which an individual has been wrongedUtilitarianismThe ethical theory on which decisions are based that ensure the greatest happiness to the greatest number of peopleFalse ImprisonmentThe deliberate and unauthorized confinement of a person within fixed limits by the use of threat or force 

-ex: restrained against own will, in bed with all side rails up, call bell out of reachMalpracticeThe failure of a professional to perform or to refrain from performing in a manner in which a reputable member within the profession would be expected to do so. Professional negligence. (must result in injury)BeneficenceAn ethical principle that refers to one's duty to benefit or promote the good of othersStatutory LawLaw that has been enacted by the legislative bodiesSlanderVerbalizing false and malicious information about a personEthical EgoismAn ethical theory that espouses making decisions based on what is most advantageous for the person making the decisionCommon LawLaw that is derived from decisions made in previous casesCivil LawLaw that protects the private and property rights of individuals and businessesChristian EthicsThe ethical theory that espouses "Do unto others as you would have others do unto you"

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VeracityEthical theory that refers to one's duty to always be truthfulEthical ConsiderationsThe nurse who works in the mental health setting is responsible for practicing ethically, competently, safely, and in a manner consistent with all local, state, and federal laws.Nurse Practice ActDefines the legal parameters of professional and practical nursingVoluntary Admission-Admission that is agreed upon by the patient to receive treatment-Tx is usually recommended -Maintains all civil rights -Pt is free to leave at any time, if mentally functional, can provide basic needs, and is not a danger to self or othersInvoluntary Admission-Admission without the pt's consent, or court ordered "Pink Slipped"-Most commonly due to:--An emergency situation (pt is danger to self or others)--For observation and treatment of mentally ill persons--When an individual is unable to take care of basic personal needs -Must show probable cause; and clear, convincing evidence-Usually 48-92 hours (72 in Ohio)Emergency Admission-Admission usually instigated by relatives, friends, police officers, court, or health care professionals. -Time limited admission, court hearing within 72 hours of admission. 

-Pt is an immediate danger to self or othersThe Mentally Ill Person In Need of Treatment-A type of involuntary admission is for the observation and treatment of the mentally ill person in need of treatment. -Vary from state to state, but generally:--Unable to make informed decisions concerning treatment--Likely to cause harm to self or others--Unable to fulfill basic personal needs necessary for health and safetyInvoluntary Outpatient Commitment-Court ordered tx after discharge-Goal is to decrease chance of readmission, and decrease length of hospital stays 

-Severe & persistent mental illness with limited awareness of illness or need for tx-History of repeated involuntary admissions-Likelihood that without tx, pt will end up being involuntary re-admitted 

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-Presence of severe & persistent mental illness with risk of becoming homeless, incarcerated, violent, or committing suicide.Competency-Individual's cognition is not impaired to an extent that would interfere with decision making or, if so, that the individual has a legal representativeSeclusion-Patient is confined alone in a room from which they cannot leave.-Locked or guarded doorRestraints-Should be used a final intervention after all other interventions have failed. 

-In an emergency, restraints may be put in place without a physician's order. However, must obtain order within 1 hour. -Orders need to be renewed based on pt's age. 18+ q4, 9-17 q2, and <9 qh. -Re-assess pt every 10-15 minutes, and documentConfidentiality-HIPPA applies unless:--Disclosing HIV status--Duty to warn and protect 3rd parties --Report child/elder abuseNegligenceNot following standards of nursing, policies and proceduresAvoiding Liability-Respond to the pt -Educate the pt-Supervise care-Adhere to the nursing process-Document carefully-Follow up as required-Develop and maintain a good interpersonal relationship with pt and family

compensationcovering up a real or perceived weakness by emphasizing a trait one considers more desirable.denialrefusal to acknowledge the existence of a real situation or the feelings associated with it.displacementfeelings are transferred from one target to another that is considered less threatening or neutral.identification

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an attempt to increase self-worth by acquiring certain attributes and characteristics of an individual whom one admires.intellectualizationan attempt to avoid expressing actual emotionsassociated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.introjectionthe beliefs and values of another individual are internalized and symbolically become a part of the self, to the extent that the feeling of separateness or distinctness is lost.isolationthe separation of a thought or a memory from the feeling, tone, or emotions associated with it.projectionfeelings or impulses unacceptable to one's self are attributed to another person.rationalizationattempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors.reaction formationpreventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors.regressiona retreat to an earlier level of development and the comfort measures associated with that level of functioning.repressionthe involuntary blocking of unpleasant feelings andexperiences from one's awareness.sublimationthe rechanneling of drives or impulses that are personally or socially unacceptable into activities that are more tolerable and constructive.suppressionthe voluntary blocking of unpleasant feelings andexperiences from one's awareness.undoinga mechanism that is used to symbolically negate or cancel out a previous action or experience that one finds intolerable.

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As a nurse approaches a client with schizophrenia, the client looks at the nurse and says, "Back off. Leave me alone." The client appears tense and is pacing rapidly. Which of the following is an appropriate nursing response.I will give you space as along as you control yourself. I'd like to know what is causing you to feel so tense.

A nurse on a mental health care unit is providing care for a client diagnosed with schizophrenia. The client is experiencing delusional thinking. Which of the following defense mechanisms is the client using when making delusional statements?Projection

A client diagnosed with schizophrenia says to the nurse, "They lied about me and are trying to poison my food." Which of the following is a therapeutic response?You're having very frightening thoughts

A client is hospitalized with schizophrenia. During a conversation with the nurse, the client seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which statement by the nurse would be appropriate at this time?What were we discussing when you began to feel uncomfortable?

A nurse is caring for a client whose provider has prescribed fluphenazine decanoate (Prolixin) 12.5 mg IM weekly. Available is fluphenazine decanoate 50 mg per 2 mL. How many mL should the nurse plan to administer each week?0.5

A nurse is caring for a client admitted for depresssion 1 week ago who was started on paroxetine (Paxil) at the time of admission. The client states to the nurse, "My family would be better off without me." Which of the following is an appropriate therapeutic response by the nurse?You sound upset. Are you thinking of hurting yourself?

A nurse should document that a client is experiencing mild anxiety when the nurse observes which of the following?The client is extremely alert

A nurse is caring for a college student at the campus mental-health counseling center. The student comes to see the nurse after getting a low grade in a course, and spends the entire session blaming the teacher and complaining about the lack of help seminars. The nurse recognizes this behavior as an example of which of the following defense mechanisms?Displacement

A client in a long term care facility asks the nurse to telephone her husband and ask him if he remembered to pickup his suit at the cleaners. The nurse knows that the client's husband died fiver years before. Which of the following is an appropriate nursing response?You miss your husband a lot, don't you?

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A client is admitted to the psychiatric unit for depression. The nurse observes an improvement in the client's grooming when the client comes to breakfast freshly bathed wearing clean clothes and with combed hair. Which of the following is an appropriate therapeutic response by the nurse?You look nice after your bath and shampoo.

While taking a health history from a client in the outpatient mental health clinic, a nurse observes that the client is persistent in making personal inquiries. Which of the following is the most therapeutic response?Explain to the client that this time is for him

A client who is bipolar states to the psychiatric nurse in the mental health outreach clinic, "I no longer take my medication because I like to feel manic." Which of the following is an appropriate therapeutic response?You feel better when you don't take your medication?

A client is admitted to the hospital with abdominal pain and gastrointestinal bleeding has a colonoscopy, and colon cancer is discovered. The provider comes to the client's room, tells the client the diagnosis, discusses treatment options, and leaves. Shortly after, the nurse enters the room and the client begins yelling at the nurse stating, "I have received lousy care here and no one cares about me." The nurse recognizes that the client is demonstrating the defense mechanism ofDisplacement

A widow is brought to the clinic by her adult son, who found her at home crying. She said that she could not go on alone. He tells the nurse that when his father died six months earlier, and the family was amazed at his mother's fortitude during and immediately after the funeral. She did not cry or seem unduly upset. The nurse recognizes that his mother had previously dealt with her husband's death by using which defense mechanism?Denial

A nurse is caring for a client with dementia. She should understand that the goal of reminiscence therapy in long-term care facilities is toshare memories of past experiences and events

A nurse is caring for a client diagnosed with borderline personality disorder. The client becomes attached to one of the nurses and refuses to talk with any of the other staff members. The client says the other staff members are abusive and untrustworthy. The client is using which of the following defense mechanisms?Splitting

The spouse of a chronic alcoholic client says to the nurse, "I told my husband I would leave if he did not get into treatment. Now that his is here, I feel differently. What can I do to help him?" Which of the following is a therapeutic nursing response?Tell me more about the kind of help you feel you are able to provide at this time.

A client with dementia says to the nurse, "Everyone wants to kill me." Which of the following statements is an appropriate nursing response?You are frightened. This is a hospital, and we are here to help.

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A nurse is caring for a client diagnosed with disorganized schizophrenia. The client does not return to a visitor's greeting and instead lies down on the bed and curls up in the fetal position. Which of the following defense mechanisms is the client exhibiting?Regression

A client was admitted to the psychiatric unit with diagnosis of bipolar disorder. At 3:00 AM, the client runs to the nurse's station and demands to see the therapist immediately. Which of the following responses by the nurse is appropriate?You must be very upset about something to want to see your therapist in the middle of the night.

Which of the following is an important short term goal for a nurse to plan with a suicidal client?Sign a contract pledging not to act on suicide plans.

A nurse is working with a depressed client notes that the client has not come to breakfast and finds the client still in bed in a nightshirt. The client tells the nurse, "I'm too sick to bother. Leave me alone and go help someone else who is worth your time." Which of the following is an appropriate response by the nurse.You sound very discouraged and hopeless today.

A nurse in an oncology unit provides support to the parents of a child newly diagnosed with a glioblastoma tumor of the brain. In planning care, the nurse understands the parents' initial reaction to a potentially terminal illness in their child isDenial and disbelief

A parent brings an 18-month-old child to the emergency room. The child sustained a fractured left femur. Which of the following statements by the parent might make the nurse suspect child abuse?My child was riding a bicycle and got the right foot caught in the spokes.

A client has been diagnosed with anorexia nervosa. The nurse would anticipate that his client will display which of the following?A poor sense of self-identity

A female client is seen in the emergency room with ecchymosis of the trunk and face. Upon direct questioning by the nurse, the client admits to having been struck by her spouse. When offered information about shelters for battered women, the client declines stating, "I could never leave my husband because of my kids." Which of the following is an appropriate nursing response?I am concerned about your safety.

A client is admitted to the detoxification center for alcohol addiction. On the day after admission, the client develops hand tremors and asks the nurse about them. Which of the following is an appropriate nursing response?They will persist for a few days now that you are not drinking.

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A nurse is working in a busy pediatric emergency room. In which of the following cases should the nurse maintain a high index of suspicion of physical child abuse?A 9 month old who reportedly nearly drowned after climbing into the tub and turning on the water.

A nurse receives a call on a crisis intervention hotline from a client who threatens to commit suicide. Which would be the most important question for the nurse to ask?How will you carry out your plan?

A nurse should recognize that magnetic resonance imaging (MRI) procedures are generally contraindicated for clients who have a fear of which of the following?Closed spaces

While working with client, a nurse unconsciously attributes negative feelings to the client and becomes antagonistic toward her. The nurse demonstrating which of the following?Countertransference

A nurse is admitting an adolescent female to the psychiatric unit for observation related to clinical depression. After completing the admission assessment, the nurse should give greatest priority to which of the following findings?The client gave her favorite necklace to her best friend

A client diagnosed with borderline personality disorder has become attached to one of the nurses who calls in sick one day. When given this news, the client breaks a glass bottle and uses it to self-inflict a deep scratch. After providing first aid, which of the following is a therapeutic nursing action in relation to the client's behavior?Help the client verbalize her feelings and reasons for the acting-out behavior.

A college junior comes to the campus health service with reports of severe epigastric distress, and the nurse discovers the client has suffered from severe bulimia since freshman year. The client tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot control it." Which of the following is an appropriate therapeutic nursing response?You are feeling helpless about changing this behavior?

A nurse is caring for a client who is scheduled for a cardiac catheterization. When arriving for the procedure, the client reports waking that morning with butterflies in the stomach, a sense of restlessness, urinary frequency, and some difficulty concentrating while driving to the hospital. The admitting nurse should asses the client's anxiety level as which of the following?Moderate

A client with hallucinations is admitted to the psychiatric unit. In the initial phase of establishing a therapeutic nurse client relationship, it would be appropriate for the nurse to explore which of the following?Perception of the presenting problem

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A nurse's neighbor has just found out that her teenage child has died in a motor-vehicle crash. The neighbor is crying inconsolably. Which of the following is an appropriate therapeutic nursing response?Sit silently with the client while he cries

The nurse asks a client who is suicidal to make a safety contract. The client states to the nurse, " I cannot make a safety contract, because I can't promise that I will not harm myself." In the nurse's plan of care, which of the following initial actions is best to ensure this client's safety when implementing the plan of care?Have a staff member stay with the client at all times.

A client is admitted to the psychiatric unit following treatment in the emergency room for an intentional overdose ingestion. As the nurse performs the admission assessment, the client says, "Why would you want to waste your time on a worthless person like me?" Which of the following is a therapeutic nursing response?I think you are worthwhile, and I want to talk to you.

A nurse should assess that the client with the highest potential for suicide is the depressed client who states which of the following?I have it all figured out. Everything is going to be okay now.

A client is admitted for the third time to a psychiatric hospital with a diagnosis of schizophrenia. During the admission procedure, the nurse notices that the client's appearance is unkempt, and the client seems to be actively hallucinating. Which of the following should be the nurse's priority nursing assessment?Physical Needs. 

Rationale: The client's appearance and behavior may be due to a physical illness or injury, or to a fluid and electrolyte imbalance. Assessing the client's physical health needs should be the initial priority for the nurse.

A nurse is caring for a client who is taking a tricyclic antidepressant. Which of the following side effects should the nurse report promptly to the client's provider?Urinary Retention. 

Rationale: Urinary retention is potentially serious side effect. In addition to monitoring the client's intake and output, the nurse should check for abd distention, hold the next dose of the antidepressant, and report the client's condition to the provider. Urinary retention can lead to bladder infection and loss of bladder tone.

A nurse is administering neuroleptic medication thioridazine hydrochloride (Mellaril) 150 mg four times a day. The client reports hand tremors, drooling, and restlessness. Which of the following is an appropriate nursing action?Administer benztropine Mesylate (Cogentin) 1mg PO (ordered PRN)

Rationale: This client is experiencing extrapyramidal system effects of Mellaril. Benztropine Mesylate (Cogentin) is the drug of choice to counteract this adverse effect

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Four days after admission, a client taking haloperidol (Haldol) is pacing. The nurse observes and assesses further by asking how the client feels. The client replies "I'm very restless and can't seem to sit still." The nurse should understand that the client is experiencing which extrapyramidal side effect?Akathesia.

Rationale:Akathesia is an extrapyramidal side effect characterized by the client's complaint of a sense of inner restlessness and observable behaviors like pacing and fidgeting.

A nurse is caring for a client who has OCD. The client engages in repeated hand washing. Which of the following is the purpose of the client's behavior?Relief of anxiety

Ritualistic behavior is associated with obsessive-compulsive disorder, an anxiety disorder. The client repeatedly performs ritualistic behaviors as a way to alleviate, or undo, anxiety.

A client diagnosed with schizophrenia. The client spends a great deal of time repeating rhyming syllables such as "Me, see, bee, tree." The nurse should recognize that the client is demonstrating use of which of the following?Clang association.

Rationale: The stringing and repeating of words together because of their rhyming sounds is called clang association. Clang association is frequently seen in clients with schizophrenia.

A nurse is caring for a client diagnosed with a severe anxiety disorder. The client is in a state of panic in the dayroom. Which of the following actions should the nurse implement initially for the client?Speak in a calm manner.

Rationale: The initial goal for the client in panic is to obtain relief. Staying with the client and speaking in a calm manner are the best initial actions for the nurse.

Which of the following defense mechanisms does a client with obsessive compulsive disorder exhibit when performing rituals.Undoing. 

Rationale:Undoing is the unconscious defense mechanism characterized by a compulsive response the negates a painful feeling or unacceptable act. Obsessive-compulsive disorder (OCD), one of the anxiety disorders, is a condition characterized by a pattern of repetitive thoughts and behaviors (rituals) that are senseless and distressing to the client, but extremely difficult to overcome. The rituals are a form of undoing to revers or negate unacceptable impulses.

A nurse plans to teach important information about the anxiolytic agent diazepam (Valium) to a client for whom it has just been prescribed. The nurse should include in the teaching plan which of the following?Valium can be habit forming.

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Rationale: Diazepam is a benzodiazepine agent. All drugs in this category can cause physical dependence and are considered controlled substances. Diazepam use can lead to additional, especially at higher dosages over prolonged periods of time.

A nurse is providing discharge teaching for a client who takes lithium (Lithane). The nurse should inform the client that which of the following could precipitate lithium toxicity?Fasting.

Rationale: Crash dieting or fasting can lead to lithium toxicity because the sodium and electrolyte balance would be altered, causing the blood levels of lithium to rise.

A client taking a tricyclic antidepressant is seen at the clinic. The client reports experiencing several side effects from the medication. Which of the following is the most common side effect associated with tricyclic antidepressants?Drowsiness.

Rationale:Drowsiness in the most common side effect of tricyclic antidepressants.

The admitting nurse asks a client what factors, such as recent life changes, have contributed to the need for hospitalization. The client replies, "Change...change the range, mange the change." The nurse should recognize this response as an example of which of the following?Clanging.

Rationale:Clanging is speech in which sounds, rather than conceptual relationships, influence word choice. It is commonly associated with schizophrenia and mania.

An emergency room nurse is admitting a client who is complaining of chest pain and dyspnea. The client is also flushed and perspiring profusely, screaming, "I am going to die! This is it! I am having a heart attack!" The medical exam and lab work are negative. The client is diagnosed with anxiety. The nurse should assess the client's level of anxiety to be which of the following?Panic.

Rationale: The client's manifestation indicate the panic level of anxiety. They are also classic symptoms of a panic disorder.

A nurse is caring for a client diagnosed with obsessive compulsive disorder. Initially, which of the following actions should the nurse consider in dealing with the client's ritualistic behaviors?Plan the client's schedule to allow extra time to perform the rituals to keep anxiety within manageable levels. 

Rationale: It is important that sufficient time be alloted for the client to perform rituals early in the treatment. This will help keep anxiety levels manageable. The key word in this question is "initially". Limit setting on the ritualistic behavior comes later in the treatment plan as the client develops other adaptive coping skills.

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A nurse asks an older adult client, "Did you have any visitors, yesterday?" The client responds, "Yes, several members of my church choir came to see me." The nurse knows that only the client's child visited the day before. Which of the following is the client demonstrating?Confabulation.

Rationale: Confabulation is filling in gabs in memory by fabrication. The client will make up responses that are inaccurate but sound appropriate. It is done to avoid the embarrassment about memory loss.

A nurse should understand that clients who are diagnosed with agoraphobia display which defense mechanism.Displacement.

Rationale: Displacement is the unconscious defense mechanism characterized by painful feelings to a neutral object. In agoraphobia, a phobic disorder, the anxiety is displaced from the original source to another object or situation, resulting in the phobia.

An emergency room nurse is assessing a client for cocaine intoxication. The nurse should know that which of the following is associated with cocaine intoxication?Paranoia. 

Rationale: Paranoid behavior can be a symptom associated with cocaine intoxication.

What information about diet should a nurse give all clients taking lithium?An adequate daily intake of sodium and fluids should be maintained.

Rationale: Consistent intake of sodium and fluids is needed to avoid lithium toxicity. Clients should be advised to contact their psychiatrist to report any medical conditions that cause them to lose sodium, such as vomiting, diarrhea, or profuse sweating. The psychiatrist will advise them on what to do to avert lithium toxicity.

An eyewitness to a violent crime is unable to give police an account of the crime and complains of blindness and a severe headache when asked to view "mug shots." Which of the following defense mechanisms is the client using?Conversion.

Which of the following is the best approach for a nurse to take initially with a client who is experiencing severe anxiety?Move the client to a calm, nonstimulating environment.

A client is admitted with a diagnosis of acute schizophrenia. The client is started on chlopromazine (Thorazine) 100mg 3 times a day for agitation. When the client is calmer, the nurse begins client teaching about the medication. The nurse knows it is appropriate to state which of the following?Thorazine will help to control the symptoms of your illness.

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A nurse is caring for a client diagnosed with somatization disorder. The nurse should understand that a client with this disorder will use which of the following defense mechanisms?Repression

The nurse discovers that a client who is depressed is an expert at crewel embroidery. After gathering some embroidery materials, the client is asked to teach the nurse this skill. Which of the following is the best rationale for this nursing intervention?Use the client's personal strengths to build self-esteem.

A nurse can evaluate the progress of a client with agoraphobia as having improved when the client is able to attend which of the following?A unit picnic in a local park.

A nurse is caring for a client in the day treatment program who is diagnosed with hypochondriasis. The client constantly reports physical problems, and the other client in the unit are beginning to avoid the client. Which of the following should the nurse's primary intervention to decrease social isolation?Encourage the client to participate in group diversional activities.

A nurse is caring for a client who has been diagnosed with bipolar disorder. The client is pregnant. Which of the following medications is appropriate for the client to take?Paroxetine (Paxil)

A nurse is planning a menu for a client with bipolar disorder who was admitted for an acute manic episode. Which of the following is an appropriate meal for this client?Chicken nuggets, ear of corn, apple

A nurse is planning care for a client with panic disorder who is taking alpraxolam (Xanax) 0.25 mh t.i.d.. Which of the following instruction should the nurse give the client?"You should increase your fluid intake to prevent dry mouth."

A nurse should understand that a common side effect of benzodiazepine antianxiety medications is which of the following?Dizziness

A client is receiving lorazepam (Ativan) for anxiety. In reviewing the client's discharge plans, the nurse should emphasize that lorazepammust be discontinued by gradual tapering over time.

A nurse is caring for a client who was admitted to a psychiatric hospital for an evaluation. The client has been unable to leave the house for the past 10 years without accompaniment. When attempting to go out alone, the client becomes very anxious and must quickly return inside. The nurse identifies the problem as which of the following?Agoraphobia.

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A client on the psychiatric unit is confirmed to have hypochondriacal disorder. The nurse is aware that the client is likely to exhibit which of the following?Preoccupation with physical health.

A client is hospitalized for an obsessive compulsive disorder with recurring thoughts of mouth odors that are offensive to others. The client also has mouth care rituals that occupy a good deal of the client's waking hours and caused him to be fired from his last job. The nurse understands that these manifestations most likely represent which of the following?Method of reducing anxiety.

A nurse is caring for a client who is experiencing the early phase of alcohol withdrawal. Which of the following should be the primary focus of nursing care?Rest and nutrition.

A nurse is providing medication teaching to a client who is prescribed the MAOI Phenelzine (Nardil). The nurse should caution the client against concurrent use of which of the following over the counter medications?Pseudophedrine (Sudafed)

A client has been taking an antipsychotic medication for 6 years, and his provider has begun tapering off the dosage. During this process, the nurse should watch for which of the following early manifestations of tardive dyskinesia?Involuntary grimacing, lip smacking, and tongue protrusion.

A nurse is caring for a client experiencing anxiety at the panic level. Which of the following should the nurse's primary goal?Reduce the client's immediate anxiety.

A client with a history of psychosis is prescribed quetiapine fumarate (Seroquel) 150mh 4times a day. Which of the following statements should the nurse include when providing the client education about his medication?Weight gain is less common with Seroquel than other atypical antipsychotics.

A nurse in the outpatient mental health clinic is interviewing a client with schizophrenia who appears to be experiencing auditory hallucinations. Which of the following should the nurse's initial action?Establish rapport with the client.

A manic client tells the nurse that his latest computer project is revolutionizing the industry. He also states "IBM and Apple are both going under because their products cannot compete with mine." In choosing how to respond, the nurse is best guided by the knowledge that this statement represents which of the following?Grandiose delusion

A client with a history of psychosis is prescribed quetiapine furmate (seroquel) 150 mg four times a day. Which of the following statements should the nurse include when providing client education about this

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medication? A. Careful of sun exposure and wear sunscreeen outside.B. While taking Seroquel, you will need to have weekly blood counts.C. Weight gain is less comon with Seroquel than with other atypical antipsychoticsD. Seroquel is effective in managing rapid-cycling manic episodes.C. Weight gain is less common with Seroquel than with other antipsychotics

A nurse should understand that clients diagnosed with agoraphobia display which defense mechanismA. DisplacementB. IsolationC. DenialD. UndoingA. Displacement.

A nurse is caring for a client who has been diagnosed with bipolar disorder. The client is pregnant. Which of the following medications is appropriate for the client to take?A. Carbamazepine (Tegretol)B. Valproric acid (Depakote)C. Paroxetine (Paxil)D. Lithium (Lithane)Paroxetine (Paxil)

A nurse is planning care for a client with panic disorder who is taking Xanax. Which of the following instructions should the nurse give the client.A. Increased you fluid intake to prevent dry mouth.B. Take this medication wth food to prevent GI upset.C. You will need to watch your caloric intake to prevent weight gain.D. Carefully read food labels to eliminate tyramine from your diet.A. You should increase your fluid intake to prevent dry mouth.

Client who witnessed a violent crime is unable to give police an acount of the crime and when viewing mugshots, complains of blindness and a severe headache. Which defense mechanism is this?A. RationalizationB. DenialC. ConversionD. Regression.C. Conversion.

Which of the following defense mechanisms does a client with obsessive compulsive disorder exhibit when preforming rituals?A. ProjectionB. UndoingC. RationalizationD. SublimationB. Undoing.

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An emercengy room nurse is admitting a client complaining of chest pain and dyspnea, Client is flushed adn sweating profusely, screaming, "I am going to die! This is it! I am having a heart attack! Which level of anxiety is the client expereincing?MildModerateSeverePanicPanic

A nurse is planning a menu for a client with bipolar disorder who is in the acute manic phase. Which is appropriate?A. Spaghetti and meatballsB. Beef and vegetable stew, bread, and vanilla puddingC. Chicken nuggets, ear or corn, appleD. Fish fillets, stewed tomatoes, cakeChicken nuggets, ear of corn, apple.

client admitted for third time to psych hopsital with schizophrenia. Clients appearance is unkempt, and the client seems to be actively hallucinating. What should be the nurses primary assessment?A. Perception of realityB. Ability to follow directionsC. Physical needsD. Mental statusC. Physical needs

Client expereincing somatization is using what defense mechanism?A. DisplacementB. RepressionC. UndoingB. Repression- characterized by involuntarily forgetting painful thoughts that manifests as physical complaints.

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