D. An interpreter will enable the nurse to better assess the client’s problems and concerns. Nonverbal communication is important; however for the nurse to fully determine the client’s problems and concerns, the assistance of an interpreter is essential. The use of symbolic pictures and universal phrases may assist the nurse in understanding the basic needs of the client; however these are insufficient to assess the client with a psychiatric problem.
D. Psychoanalytic is based on Freud’s beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other. Behavioral cognitive and interpersonal theories do not emphasize unconscious conflicts as the basis for symptomatic behavior.
D. By acknowledging the observed behavior and asking the client to express his feelings the nurse can best assist the client to become aware of his anxiety. In option A, the nurse is offering an interpretation that may or may not be accurate; the nurse is also asking a question that may be answered by a “yes” or “no” response, which is not therapeutic. In option B, the nurse is intervening before accurately assessing the problem. Option C, which also encourages a “yes” or “no” response, avoids focusing on the client’s anxiety, which is the reason for his pacing.
A. A client with obsessive-compulsive behavior uses this behavior to decrease anxiety. Accepting this behavior as the client’s attempt to feel secure is therapeutic. When a specific treatment plan is developed, other nursing responses may also be acceptable. The remaining answer choices will increase the client’s anxiety and therefore are inappropriate.
A. Education and work history would have the least significance in relation to the client’s sexual problem. Age, health status, physical attributes and relationship issues have great influence on sexual expression.
C. Inpatient treatment of a client with anorexia usually focuses initially on establishing a plan for refeeding to combat the effects of self-induced starvation. Refeeding is accomplished through behavioral therapy, which uses a system of rewards and reinforcements to assist in establishing weight restoration. Emphasizing nutrition and teaching the client about the long-term physical consequences of anorexia maybe appropriate at a later time in the treatment program. The nurse needs to assess the client’s mealtime behavior continually to evaluate treatment effectiveness.
A. One of the core issues concerning the family of a client with anorexia is control. The family’s acceptance of the client’s ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addressed in these responses.
D. The client with a somatoform disorder displaces anxiety onto physical symptoms. The ability to express anxiety verbally indicates a positive change toward improved health. The remaining responses do not indicate any positive change toward increased coping with anxiety.
C. Directly questioning a client about suicide is important to determine suicide risk. The client may not bring up this subject for several reasons, including guilt regarding suicide, wishing not to be discovered, and his lack of trust in staff. Behavioral cues are important, but direct questioning is essential to determine suicide risk. Indirect questions convey to the client that the nurse is not comfortable with the subject of suicide and, therefore, the client may be reluctant to discuss the topic.
C. A client exhibiting flight of ideas typically has a continuous speech flow and jumps from one topic to another. Speaking in coherent sentences is an indicator that the client’s concentration has improved and his thoughts are no longer racing. The remaining options do not relate directly to the stated nursing diagnosis.
C. The nurse should take any nurse statements indicating suicidal thoughts seriously and further assess for other risk factors. The remaining diagnoses fail to address the seriousness of the client’s statement.
D. This statement provides accurate information and an element of hope for the family of a schizophrenic client. Although the remaining statements are true, they do not provide the empathic response the family needs after just learning about the diagnosis. These facts can become part of the ongoing teaching.
A. A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events. The client with a distorted perception of the environment would not necessarily have impairments affecting hygiene and grooming skills. Although taking medications and participating in unit activities may be appropriate outcomes for nursing intervention, these responses are not related to client perceptions.
D. A client with these symptoms would have poor impulse control and would thereforebe prone to acting-out behavior that may be harmful to either himself or others. All of the remaining nursing diagnoses may apply to the client with mania; however, the priority diagnosis would be risk for violence.
C. Rationalization is the defense mechanism that involves offering excuses for maladaptive behavior. The client is defending his substance abuse by providing reasons related to life stressors. This is a common defense mechanism used by clients with substance abuse problems. None of the remaining defense mechanisms involves making excuses for behaviors.
B. Physical aggressiveness, low stress tolerance, and a disregard for the rights of others are common behaviors in clients with conduct disorders. Restlessness, short attention span, and hyperactivity are typical behaviors in a client with attention deficit hyperactivity disorder. Deterioration in social functioning, excessive anxiety and worry and bizarre behaviors are typical in schizophrenic disorders. Sadness, poor appetite, sleeplessness, and loss of interest in activities are behaviors commonly seen in depressive disorders.
B. Babies born to heroin-dependent women are also heroin-dependent and need to go through withdrawal. There is no evidence to support any of the remaining answer choices.
D. Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur. The nurse will also need to preserve the client’s privacy and identify the extent of injury. However, it is essential that the nurse follow legal and agency guidelines for preserving evidence. Identifying the assailant is the job of law enforcement, not the nurse.
D. Socioeconomic status is not a reliable predictor of abuse in the home, so it would be the least important consideration in deciding issues of safety for the victim of family violence. The availability of appropriate community shelters and the ability of the nonabusing caretaker to intervene on the client’s behalf are important factors when making safety decisions. The client’s response to possible relocation (if the client is a competent adult) would be the most important factor to consider; feelings of empowerment and being treated as a competent person can help a client feel less like a victim.
A. In the early stage of Alzheimer’s disease, complex tasks (such as balancing a checkbook) would be the first cognitive deficit to occur. The loss of self-care ability, problems with relating to family members, and difficulty remembering one’s own name are all areas of cognitive decline that occur later in the disease process.
C. The client with Alzheimer’s disease can have frequent episode of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the client’s attention. An over stimulating environment may cause the labile mood, which will be difficult for the client to understand. The client with Alzheimer’s disease loses the cognitive ability to respond to either humor or logic. The client lacks any insight into his or her own behavior and therefore will be unaware of any causative factors.
A. A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of Alzheimer’s disease will act to increase available acetylcholine in the brain. The remaining neurotransmitters have not been implicated in Alzheimer’s disease.
C. The most important factors to determine in this situations are the client’s perception of the crisis event and the availability of support (including family and friends) to provide basic needs. Although the nurse should assess the other factors, they are not as essential as determining why the client considers this a crisis and whether he can meet his present needs.
D. Crisis intervention is based on the idea that a crisis is a disturbance in homeostasis (steady state). The goal is to help the client return to a previous level of equilibrium in functioning. The remaining answer choices are not considered the primary outcome of crisis intervention, although they may occur as a side benefit.
B. Increased anxiety and uncertainly characterize the initiation phase in group therapy. Group members are more self-reliant during the working and termination phases.
A. As the group progresses into the working phase, group members assume more responsibility for the group. The leader becomes more of a facilitator. Comments about behavior in a group are indicators that the group is active and involved. The remaining answer choices would indicate the group progress has not advanced to the working phase.
C. The use of diuretics would cause sodium and water excretion, which would increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to increase their fluid intake and to maintain normal intake of sodium. Concurrent use of any of the remaining medications will not increase the risk of lithium toxicity.
D. In a functional family, parents typically do not agree on all issues and problems. Open discussion of thoughts and feeling is healthy, and parental disagreement should not cause system stress. The remaining answer choices are life transitions that are expected to increase family stress.
A. Aged cheese and red wines contain the substance tyramine which, when taken with an MAOI, can precipitate a hypertensive crisis. The other foods and beverages do not contain significant amounts of tyramine and, therefore, are not restricted.
C. Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the client’s blood pressure (lying, sitting, and standing) before administering this drug. If the client had taken the drug previously, the nurse would also need to assess the skin color and sclera for signs of jaundice, a possible drug side affect; however, based on the information given here, there is no evidence that the client has received chlorpromazine before. Although the drug can cause urine retention, asking the client to avoid will not alter this anticholinergic effect.
B. The onset of action of the SSRI antidepressant paroxetine occurs around 3 to 4 weeks after drug therapy begins. Therefore, a client will seldom notice improvement before this time. Continuing to take the drug is important for this client.
B. Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs, possibly causing a hypertensive crisis. None of the remaining medications will increase the sympathomimetic response and, therefore, are not contraindicated.
C. Urinary retention is a common anticholinergic side effect of psychotic medications, and the client with benign prostatic hypertrophy would have increased risk for this problem. Adding fiber to one’s diet and exercising regularly are measures to counteract another anticholinergic effect, constipation. Depending on the specific medication and how it is prescribed, taking the medication at night may or may not be important. However, it would have nothing to do with urinary retention in this client.
B. Coffee contains caffeine, which has a stimulating effect on the central nervous system that will counteract the effect of the antianxiety medication oxazepam. None of the remaining foods is contraindicated.
B. The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety. Although each of the remaining answer choices may be an outcome of attendance at Alcoholics Anonymous, the primary purpose is directed toward sobriety of members.
C. A therapeutic community is designed to help individuals assume responsibility for themselves, to learn how to respect and communicate with others, and to interact in a positive manner. The remaining answer choices may be outcomes of psychiatric treatment, but the use of a therapeutic community approach is concerned with promotion of self-reliance and cooperative adaptation to being with others.
ADCBE. The nurse should remain with the client to provide support and promote safety. Reducing external stimuli, including dimming lights and avoiding crowded areas, will help decrease anxiety. Encouraging the client to use slow, deep breathing will help promote the body’s relaxation response, thereby interrupting stimulation from the autonomic nervous system. Encouraging physical activity will help him to release energy resulting from the heightened anxiety state; this should be done only after the client has brought his breathing under control. Teaching coping measures will help the client learn to handle anxiety; however, this can only be accomplished when the client’s panic has dissipated and he is better able to focus.
C. Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml
C. The initial, most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time, place, and person). The nurse may also assess for confabulation and perseveration in a client with cognitive impairment; but the questions in this situation would not elicit the symptom response. Delirium is a type of cognitive impairment; however, other symptoms are necessary to establish this diagnosis.
D. Short words and simple sentence minimize client confusion and enhance communication. Complete explanations with multiple details and stimulating words and phrases would increase confusion in a client with short attention span and difficulty with comprehension. Although pictures and gestures may be helpful, they would not substitute for verbal communication.
D. Confabulation is a communication device used by patients with dementia to compensate for memory gaps. The remaining answer choices are incorrect.
C. Maintaining a calm approach when intervening with an agitated client is extremely important. Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Restraints are a last resort to ensure client safety and are inappropriate in this situation. Sedation should be avoided, if possible, because it will interfere with CNS functioning and may contribute to the client’s confusion.
C. Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The other options are incorrect responses, although all may be seen in this client.
D. Following established activity schedules is a realistic expectation for clients with dementia. All of the remaining outcome statements require a higher level of cognitive ability than can be realistically expected of clients with this disorder.
C. The family’s perception of the problem is essential because change in any one part of a family system affects all other parts and the system as a whole. Each member of the family has been affected by the current problems related to the school system and the nurse would be interested in the data. The child’s performance in school and the teacher’s attempts to solve the problem are relevant and may be assessed; however, priority would be given to the family’s perception of the problem. The family education and work history may be relevant, but are not a priority.
B. Te parents are feeling responsible and this inappropriate self-blame can be limited by supplying them with the facts about the biologic basis of schizophrenia. Acknowledging the patient’s responsibility is neither accurate nor helpful to the parents and would only reinforce their feelings of guilt. Support groups are useful; however, the nurse needs to handle the parents’ self-blame directly instead of making a referral for this problem. Teaching the parents various ways to change would reinforce the parental assumption of blame; although parents can learn about schizophrenia and what is helpful and not helpful, the approach suggested in this option implies the parents’ behavior is at fault.
A. Family boundaries are parameters that define who is inside and outside the system. The best method of obtaining this information is asking the family directly who they consider to be members. The question asked by the nurse would not elicit information about the family’s ethnicity or culture, nor does it address the nature of the family relationship.
B. Differentiation is the process of becoming an individual developing autonomy while staying in contact with the family system. Cooperative action among family members does not refer to differentiation, although individuals who have a high level of differentiation would be able to accomplish cooperative action. Incongruent messages in which the recipient is a victim describe double-bind communication. Maintenance of system continuity or equilibrium is homeostasis.
D. The nurse who wishes to be helpful to the entire family must remain neutral. Taking sides in a conflict situation in a family will not encourage negotiation, which is important for problem resolution. If the nurse aligned with the adolescent, then the nurse would be blaming the parents for the child’s current problem; this would not help the family’s situation. Learning to negotiate conflict is a function of a healthy family. Encouraging the parents to adopt more realistic rules or the adolescent to comply with parental rules does not give the family an opportunity to try to resolve problems on their own.
C. Enmeshment is a fusion or overinvolvement among family members whereby the expectation exists that all members think and act alike. The child who always acts to please her parents is an example of how enmeshment affects development in many cases, a child who develops anorexia nervosa exerts control only in the area of eating behavior. The remaining options are not appropriate to the situation described.