1) The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client?
- Ping pong
2) A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of imbalanced nutrition related to poor nutritional intake. The most appropriate nursing intervention related to this diagnosis is:
- Explain to the client the importance of a good nutritional intake
- Weight the client 3 times per week before breakfast
- Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as possible.
- Consult with the nutritionist, offer the client several small meals per day, and schedule brief nursing interactions with the client during these times.
3) In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plans is best?
- Provide an activity that is quiet and solitary to avoid increased fatigue, such as working on a puzzle or reading a book.
- Plan nothing until the client asks to participate in milieu.
- Offer the client a menu of daily activities and insist the client participate in all of them
- Provide a structured daily program of activities and encourage the client to participate.
4) The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as “I’m such a failure… I can’t do anything right!” The best nursing response would be:
- To tell the client this is not true; that we all have a purpose in life.
- To remain with the client and sit in silence; this will encourage the client to verbalize feelings
- To reassure the client that you know how the client is feeling and that things will get better
- To identify recent behaviors or accomplishments that demonstrates skill ability.
5) A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client’s:
- Disturbed thought processes
- Imbalanced nutrition
- Self-care deficit
- Deficient knowledge
6) A depressed client is ready for discharge. The nurse feels comfortable that the client has a good understanding of the disease process when the client states:
- “I’ll never let this happen to me again. I won’t let my boss or my job or my family get to me!”
- “It’s important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or not sleep well, I’ve got to get in to see my doctor.”
- “I’ve learned that I’m a good person and that I am worthy of giving and receiving love. I don’t need anyone; I have myself to rely on!”
- “I don’t know what happened to me. I’ve always been able to make decisions for myself and for my business. I don’t ever want to feel so weak or vulnerable again!”
7) The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse’s immediate intervention is the client’s:
- Outlandish behaviors and inappropriate dress
- Grandiose delusions of being a royal descendent of King Arthur.
- Nonstop physical activity and poor nutritional intake
- Constant, incessant talking that includes sexual innuendoes and teasing the staff
8) The nurse reviews the activity schedule for the day and plans which activity for the manic client?
- Brown-bag luncheon and book review
- Paint-by-number activity
- Deep breathing and progressive relaxation group
9) A hospitalized client is being considered for ECT. The client appears calm, but the family is anxious. The client’s mother begins to cry and states “My son’s brain will be destroyed. How can the doctor do this to him?” The nurses best response is:
- “It sounds as though you need to speak with the psychiatrist”
- “Your son has decided to have this treatment. You should be supportive to him.”
- “Perhaps you’d like to see the ECT room and speak to the staff.”
- “It sounds as though you have some concerns about the ECT procedure. Why don’t we sit down together and discuss any concerns you may have.”
10) The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the most appropriate action would be to:
- With assistance, escort the manic client to her room and administer Haldol as prescribed if needed
- Tell the client that smoking privileges are revoked for 24 hours
- Orient the client to time, person, and place
- Tell the client that the behavior is not appropriate.
11) Select all nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior.
- Communicate expected behaviors to the client
- Enforce rules and inform the client the he or she will not be allowed to attend group therapy sessions.
- Ensure that the client knows that he or she is not in charge of the nursing unit
- Be clear with the client regarding the consequences of exceeding limits set regarding behavior.
- Assist the client in testing out alternative behaviors for obtaining needs
12) A woman comes into the ER in a severe state of anxiety following a car accident. The most appropriate nursing intervention is to:
- Remain with the client
- Put the client in a quiet room
- Teach the client deep breathing
- Encourage the client to talk about their feelings and concern.
13) When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. The most appropriate maintenance goal should focus on which of the following?
- Continued contact with a crisis counselor
- Identifying anxiety-producing situations
- Ignoring feelings of anxiety
- Eliminating all anxiety from daily situations
14) The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremors?
- Hypertension, changes in LOC, hallucinations
- Hypotension, ataxia, hunger
- Stupor, agitation, muscular rigidity
- Hypotension, coarse hand tremors, agitation
15) The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse “I should get out of this bad situation.” The most helpful response by the nurse would be:
- “I agree with you. You should get out of this situation.”
- “What do you find difficult about this situation?”
- “Why don’t you tell your husband about this?”
- “This is not the best time to make that decision.”
16) The nurse determines that the wife of an alcoholic client is benefiting from attending Al-Anon group when she hears the wife say:
- “My attendance at the meetings has helped me to see that I provoke my husband’s violence.”
- “I no longer feel that I deserve the beatings my husband inflicts on me.”
- “I can tolerate my husband’s destructive behavior now that I know they are common with alcoholics.”
- “I enjoy attending the meetings because they get me out of the house and away from my husband.”
17) The client has been hospitalized and is participating in a substance abuse therapy group sessions. On discharge, the client has consented to participate in AA community groups. The nurse is monitoring the client’s response to the substance abuse sessions. Which statement by the client best indicates that the client has developed effective coping response styles and has processed information effectively for self use?
- “I know I’m ready to be discharged. I feel I can say ‘no’ and leave a group of friends if they are drinking… ‘No Problem.’”
- “This group has really helped a lot. I know it will be different when I go home. But I’m sure that my family and friends will all help me like the people in this group have… They’ll all help me… I know they will… They won’t let me go back to my old ways.”
- “I’m looking forward to leaving here. I know that I will miss all of you. So, I’m happy and I’m sad, I’m excited and I’m scared. I know that I have to work hard to be strong and that everyone isn’t going to be as helpful as you people.”
- “I’ll keep all my appointments; go to all my AA groups; I’ll do everything I’m supposed to… Nothing will go wrong that way.”
18) A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I have to go. I don’t want anymore treatment. I have things that I have to do right away.” The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client’s concerns with the client, the client dresses and begins to walk out of the hospital room. The most important nursing action is to:
- Restrain the client until the physician can be reached
- Call security to block all areas
- Tell the client that the client cannot return to this hospital again if the client leaves now.
- Call the nursing supervisor.
19) Select the appropriate interventions for caring for the client in alcohol withdrawal.
- Monitor vital signs
- Provide stimulation in the environment
- Maintain NPO status
- Provide reality orientation as appropriate
- Address hallucinations therapeutically
20) Which of the following nursing actions would be included in a care plan for a client with PTSD who states the experience was “bad luck”?
- Encourage the client to verbalize the experience
- Assist the client in defining the experience
- Work with the client to take steps to move on with his life
- Help the client accept positive and negative feelings
21) Which of the following psychological symptoms would the nurse expect to find in a hospitalized client who is the only survivor of a train accident?
22) Which of the following communication guidelines should the nurse use when talking with a client experiencing mania?
- Address the client in a light and joking manner
- Focus and redirect the conversation as necessary
- Allow the client to talk about several different topic
- Ask only open ended questions to facilitate conversations
23) What information is important to include in the nutritional counseling of a family with a member who has bipolar disorder?
- If sufficient roughage isn’t eaten while taking lithium, bowel problems will occur.
- If the intake of carbohydrates increases, the lithium level increases.
- If the intake of calories is reduced, the lithium level will increase
- If the intake of sodium increases, the lithium level will decrease.
24) In conferring with the treatment team, the nurse should make which of the following recommendations for a client who tells the nurse that everyday thoughts of suicide are present?
- A no-suicide contract
- Weekly outpatient therapy
- A second psychiatric opinion
- Intensive inpatient treatment
25) Which of the following short term goals is most appropriate for a client with bipolar disorder who is having difficulty sleeping?
- Obtain medication for sleep
- Work on solving a problem
- Exercise before bedtime
- Develop a sleep ritual
- B. Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games can stimulate aggression and increase psychomotor activity.
- D. Change in appetite is one of the major symptoms of depression. Reporting to the psychiatrist and nutritionist is to some degree correct but lacks the method as to how one would increase food intake.
- D. A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Option 3 is a forceful and absolute approach.
- D. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences for the client that are challenging but will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1 and 3 give advice and devalue the client’s feelings.
- A. major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client’s psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person’s capacity to deal with the demands of life. Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option 1 is correct.
- B. The exact cause of depression is not known but is believed to be related to biochemical disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatment for the disease process.
- C. Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominately elevated, expansive, or irritable. All options reflect a client’s possible symptomatology. Option 3, however, clearly presents a problem that compromises one’s physiological integrity and needs to be addressed immediately.
- B. A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow use of excess energy yet not endanger others during the process. Options 1, 3, and 4 are relatively sedate activities that require concentration, a quality that is lacking in the manic state. Such activities lead to increased frustration and anxiety for the client. Tetherball is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy that the client is experiencing.
- D. The nurse encourages the client and the family to verbalize fears and concerns. The other options avoid dealing with concerns and are blocks to communication.
10. A. The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to Haldol. Option 2 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse.
11. A, D, and E. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a non-punishment manner; and assisting the client in identifying strengths and in testing out alternative behaviors for obtaining needs. Enforcing rules and informing the client that he or she will not be allowed to attend group therapy sessions is a violation of the client’s rights. Ensuring the client knows that he or she is not in charge of the nursing unit is inappropriate, power struggles need to be avoided.
12. A. If a client with severe anxiety is left alone; the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
13. B. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Elimination anxiety from life is impossible.
14. A. Some of the symptoms associated with delirium tremors typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in LOC, agitation, fever, and delusions.
15. B. The most helpful response is one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.
16. B. Al-Anon support groups are protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavior changes. Option 2 is the most healthy response because is exemplifies and understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control.
17. C. In the defense mechanism of denial the person denies reality. Option 1 identifies denial. In option 2 the client is relying heavily on others, and the client’s focus of control is external. In option 4 the client is concrete and procedure oriented; again the client identifies that “Nothing will go wrong that way” if the client follows all the directions. In option 3 the client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in that statement.
18. D. A nurse can be charged with false imprisonment if a client is made to believe wrongfully that the client cannot leave the hospital. Most health care facilities have documents that the client is asked to sign that relate to the client’s responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold him against his will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise.
19. A, D, and E. When the client is experiencing withdrawal of alcohol, the priority of care is to prevent the client from harming himself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained.
20. B. The client must define the experience as traumatic to realize the situation wasn’t under his personal control. Encouraging the client to verbalize the experience without first addressing the denial isn’t a useful strategy. The client can move on with life only after acknowledging the trauma and processing the experience. Acknowledgement of the actual trauma and verbalization of the event should come before the acceptance of feelings.
21. A. Denial can act as a protective response. The client tends to be overwhelmed and disorganized by the trauma, not indifferent to it. Perfectionism is more commonly seen in clients with eating disorders, not in clients with PTSD. Clients who have had a severe trauma often experience an inability to trust others.
22. B. To decrease stimulation, the nurse should attempt to redirect and focus the client’s communication, not allow the client to talk about different topics. By addressing the client in a light and joking manner, the conversation may contribute to the client’s feeling out of control. For a manic client, it’s best to ask closed questions because open-minded questions may enable the client to talk endlessly, again possibly contributing to the client’s feeling out of control.
23. D. Any time the level of sodium increases, such as with a change in the dietary intake, the levels of lithium will decrease.
24. D. For a client thinking about suicide on a daily basis, inpatient care would be the best intervention. Although a no-suicide contract is an important strategy, this client needs additional care. The client needs a more intensive level of care than weekly outpatient therapy. Immediate intervention is paramount, not a second psychiatric opinion.
25. D. A sleep ritual or nighttime routine helps the client to relax and prepare for sleep. Obtaining sleep medication is a temporary solution. Working on problem solving may excite the client rather than tire him. Exercise before retiring is inappropriate.