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; Therapeutic
Ns. 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 therapeutic

Pt: "my daddy always tucked me into bed at night."

Ns: "I'd like to talk more about your relationship with your father."
Focusing; therapeutic

Ns to Pt: "Good morning, Sue. I see you are wearing the hair bow you made in OT."
Giving recognition; Therapeutic

Pt: "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-therapeutic

Pt: "Do you think I should get a divorce?"

Ns: What do you think would be best for you?"
Reflecting; therapeutic

Pt: "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-therapeutic

Pt: "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-Therapeutic

Pt: (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; therapeutic

Pt: " I don't think my life will ever be the same again."
Ns: "Cheer up. Everything is going to be okay."
Giving reassurance-non therapeutic

Pt:"I feel like such a failure in the eyes of my family."

Ns: "You feel as though you have let your family down."
Restating-therapeutic

Pt: "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 therapeutic

Pt: "Good morning, nurse."

Ns: "Good morning, Patricia. What would you like to talk about today?"
Giving broad opening-Thearpeutic
1


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 therapeutic

Pt: "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 therapeutic

mechanism of action of antidepressant medications

targets 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 risk

When would you expect the client to begin showing signs of relief after
antidepressant therapy?
1-4 weeks

example of a tricyclic anti-depressant

Tofranil, Anafaril

example of an MAOI
Nardil, Parnate, Marplan

example of an SSRI
Zoloft, Prozac, Celexa, Lexapro, Paxil,Luvox, Symbyax

common side effects and nursing implications for tricyclic antidepressants

-orthostatic hypotension, anti-cholinergic s/e
-increase fluid, fiber, sugar free candy

most potentially life-threatening adverse effects of MAOIs; symptoms to be on the

alert for
-hypertensive crisis
-headache, NVD
-3rd line

Lithium carbonate is commonly prescribed for?

Bipolar disorder

Many times when these individuals are started on lithium therapy, the physician also
orders an antipsychotic medication. why?
antipsychotic causes immediate effect

Therapeutic range and signs and symptoms of lithium toxicity

.6-1.5
>1.5 is toxic; blurred vision, ataxia, slurred speech, confusion, NVD

nursing implications for client on lithium therapy

2

give with food and enough sodium and fluid

mechanism of action for anxiolytics

CNS depression, immediate action

most commonly used group of anxiolytics

benzodiazipene

what 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 seizure

mechanism of action for antipsychotics

targets neurotransmitter dopamine

examples of older "typical" antipsychotics

Thorazine, Haldol

examples of newer "atypical" antipsychotics

Clozaril, Abilify

potential adverse hormonal effects associated with antipsychotic meds

gynamasteria, decreased libido, hyperprolacteria, amenorrhea, weight gain

Symptoms of agranulocytosis
fever, malaise, and sore throat

symptoms for NMS (neuroleptic malignant syndrome)

high fever, muscle rigidity, tachycardia

symptoms of EPS
acathesia, restlessness, distonia, pseudo Parkinson's

medication prescribed for EPS

benzatropine-Cogentin, progentin, benedryl

life threatening situation that could occur if client abruptly withdrawals from long
term use of CNS stimulants
severe depression with thoughts of suicide

Nurse Jones does not approve of Pam' s gay lifestyle but accepts her unconditionally
nonetheless
Respect

Nurse jones and Pam develop an immediate mutual regard for each other
rapport

Pam knows that Nurse Jones is always honest with her and will tell her the truth
even if it is sometimes painful
genuineness
3


Pam knows that Nurse Jones will not tell anyone else about what they discuss in
therapy
trust

when pam talks about her problems, Nurse Jones listens objectively and encourages
Pam to reflect on her feelings about the situation
Empathy

Pam and nurse set goals for their time together.

Orientation (Introductory) phase

Nurse reads Pam's previous medical records

pre-interaction phase

Having identified Pam's problem, they discuss aspects for possible change and ways
to accomplish them
Working phase

They establish a mutual contract for intervention

Orientation (Introductory) Phase

The established goals have been met

termination phase

Nurse explores her feelings about working with a gay person

pre-interaction phase

Pam weighs the benefits and consequences of various alternatives to change

working phase

pam and nurse discuss a plan of action for pam to employ in the advent of stressful
situations following therapy
termination phase

pam cries and says she cannot stop coming to therapy

termination phase

Nurse gives Pam positive feedback for attempting to make adaptive changes in her
life
woking phase

mary stole some makeup off of the shelf at the store

Id

Mary began to feel very guilty for taking the makeup after she got home with it
superego

mary took the makeup back to the store and apologized to the clerk for taking it
Ego
4


2 year old sandy has a temper tantrum when her mother takes a dangerous toy away
from her
Id

sandy sucks on her thumb for comfort

Id

frankie wants to do well on her algebra test and stays home to study instead of going
out with his friends
Ego

Frankie does not do as well on the algebra test as he had hoped. he becomes
despondent and refuses to come out of his room
super ego

jack joins his friends when they invite him to drink beer and smoke marijuana with
them
Id

after having a few beers, jack decides not to drive his car home.
Ego

Jack tells his parents he is sorry for drinking and smoking

super 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 integrity

Five-year old girl believes she is the cause of her parents divorce
guilt

" 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
5


"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."
Intimacy

Common side effects of anxiolytics

drowsiness, 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."
Despair

I 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

Kantianism
Ethical theory by which decisions are based on a sense of duty

Libel
Writing false and malicious information about a person

Battery
The un-consented touching of another person

Criminal Law
Provides protection from conduct deemed injurious to the public welfare

Nonmaleficence
Abstaining from negative acts toward another, including acting carefully to avoid
harm

Assault
An act that results in a person's genuine fear and apprehension that he or she will be
touched without consent

Natural Law
The theory on which decisions are based in which evil acts are never condoned, even
if they are intended to advance the noblest of ends

Torts
A violation of a civil law in which an individual has been wronged

Utilitarianism
The ethical theory on which decisions are based that ensure the greatest happiness to
the greatest number of people

False Imprisonment
The 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 reach

Malpractice
The 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)

Beneficence
An ethical principle that refers to one's duty to benefit or promote the good of others

Statutory Law
Law that has been enacted by the legislative bodies

Slander
Verbalizing false and malicious information about a person

Ethical Egoism
An ethical theory that espouses making decisions based on what is most advantageous
for the person making the decision

Common Law
Law that is derived from decisions made in previous cases

Civil Law
Law that protects the private and property rights of individuals and businesses

Christian Ethics
The ethical theory that espouses "Do unto others as you would have others do unto
you"

Veracity
Ethical theory that refers to one's duty to always be truthful

Ethical Considerations
The 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 Act

Defines the legal parameters of professional and practical nursing

Voluntary 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 others

Involuntary 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 others

The 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 safety

Involuntary 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
8

-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 representative

Seclusion
-Patient is confined alone in a room from which they cannot leave.
-Locked or guarded door

Restraints
-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 document

Confidentiality
-HIPPA applies unless:
--Disclosing HIV status
--Duty to warn and protect 3rd parties
--Report child/elder abuse

Negligence
Not following standards of nursing, policies and procedures

Avoiding 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
compensation
covering up a real or perceived weakness by emphasizing a trait one considers more
desirable.

denial
refusal to acknowledge the existence of a real situation or the feelings associated with
it.

displacement
feelings are transferred from one target to another that is considered less threatening or
neutral.

identification
9

an attempt to increase self-worth by acquiring certain attributes and characteristics of

an individual whom one admires.

intellectualization
an attempt to avoid expressing actual emotions
associated with a stressful situation by using the intellectual processes of logic,
reasoning, and analysis.

introjection
the 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.

isolation
the separation of a thought or a memory from the feeling, tone, or emotions associated
with it.

projection
feelings or impulses unacceptable to one's self are attributed to another person.

rationalization
attempting to make excuses or formulate logical reasons to justify unacceptable
feelings or behaviors.

reaction formation
preventing unacceptable or undesirable thoughts or behaviors from being expressed by
exaggerating opposite thoughts or types of behaviors.

regression
a retreat to an earlier level of development and the comfort measures associated with
that level of functioning.

repression
the involuntary blocking of unpleasant feelings and
experiences from one's awareness.

sublimation
the rechanneling of drives or impulses that are personally or socially unacceptable into
activities that are more tolerable and constructive.

suppression
the voluntary blocking of unpleasant feelings and
experiences from one's awareness.

undoing
a mechanism that is used to symbolically negate or cancel out a previous action or
experience that one finds intolerable.

10

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?
11


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?

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

12

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 of
Displacement

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 to
share 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

13

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.

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.

14

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
is
Denial 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.

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.
15


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?
16

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

A nurse's neighbor has just found out that her teenage child has died in a motorvehicle 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.

17

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

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?

18

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
19

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.
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?

20

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.

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.

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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.

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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.

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)

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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 lorazepam
must 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.

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.

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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.

25

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 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 antipsychotics
D. 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 mechanism
A. Displacement
B. Isolation
C. Denial
D. Undoing
A. 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)
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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. Rationalization
B. Denial
C. Conversion
D. Regression.
C. Conversion.

Which of the following defense mechanisms does a client with obsessive compulsive
disorder exhibit when preforming rituals?
A. Projection
B. Undoing
C. Rationalization
D. Sublimation
B. Undoing.

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?
Mild
Moderate
Severe
Panic
Panic
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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 meatballs
B. Beef and vegetable stew, bread, and vanilla pudding
C. Chicken nuggets, ear or corn, apple
D. Fish fillets, stewed tomatoes, cake
Chicken 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 reality
B. Ability to follow directions
C. Physical needs
D. Mental status
C. Physical needs

Client expereincing somatization is using what defense mechanism?

A. Displacement
B. Repression
C. Undoing
B. Repression- characterized by involuntarily forgetting painful thoughts that manifests as physical
complaints.

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