Beruflich Dokumente
Kultur Dokumente
1. Answer: D. Use the services of an interpreter. 4. Answer: A. Accepting the clients obsessive-compulsive
behaviors
An interpreter will enable the nurse to better assess the clients
problems and concerns. A client with obsessive-compulsive behavior uses this behavior
universal phrases may assist the nurse in understanding the Options B, C, and D: The remaining answer choices
basic needs of the client; however these are insufficient to will increase the clients anxiety and therefore are
assess the client with a psychiatric problem. inappropriate.
Psychoanalytic is based on Freuds beliefs regarding the Education and work history would have the least significance in
importance of unconscious motivation for behavior and the role relation to the clients sexual problem.
of the id and superego in opposition to each other.
Options B, C, and D: Age, health status, physical
Options A and B: Behavioral cognitive and attributes and relationship issues have great influence on
interpersonal theories do not emphasize unconscious conflicts sexual expression.
as the basis for symptomatic behavior.
6. Answer: C. Help establish a plan using privileges and
3. Answer: D. I notice that youre pacing. How are you restrictions based on compliance with refeeding.
feeling?
Inpatient treatment of a client with anorexia usually focuses
By acknowledging the observed behavior and asking the client initially on establishing a plan for refeeding to combat the
to express his feelings the nurse can best assist the client to effects of self-induced starvation. Refeeding is accomplished
become aware of his anxiety. through behavioral therapy, which uses a system of rewards
may or may not be accurate; the nurse is also asking a Options A and D: Emphasizing nutrition and teaching
question that may be answered by a yes or no response, the client about the long-term physical consequences of
which is not therapeutic. anorexia maybe appropriate at a later time in the treatment
In option B, the nurse is intervening before accurately program.
assessing the problem.
Option B: The nurse needs to assess the clients Option D: Indirect questions convey to the client that
mealtime behavior continually to evaluate treatment the nurse is not comfortable with the subject of suicide and,
7. Answer: A. The parents reinforce increased decision 10. Answer: C. The client speaks in coherent sentences
One of the core issues concerning the family of a client with speech flow and jumps from one topic to another. Speaking in
anorexia is control. The familys acceptance of the clients coherent sentences is an indicator that the clients
ability to make independent decisions is key to successful concentration has improved and his thoughts are no longer
Options B, C, and D: Although the remaining options Options A, B, and D: The remaining options do not
may occur during the process of therapy they would not relate directly to the stated nursing diagnosis.
issues of dependence and independence are not addressed in 11. Answer: C. Risk for self-directed violence
these responses.
The nurse should take any nurse statements indicating suicidal
8. Answer: D. The client will express anxiety verbally thoughts seriously and further assess for other risk factors.
The client with a somatoform disorder displaces anxiety into address the seriousness of the clients statement.
Directly questioning a client about suicide is important to facts can become part of the ongoing teaching.
Option A: The client may not bring up this subject for interpretation of daily events in the unit.
environment would not necessarily have impairments affecting excessive anxiety and worry and bizarre behaviors are typical
participating in unit activities may be appropriate outcomes for loss of interest in activities are behaviors commonly seen in
nursing intervention; these responses are not related to client depressive disorders.
perceptions.
17. Answer: B. Heroin dependence.
A client with these symptoms would have poor impulse control dependent and need to go through withdrawal. There is no
and would therefore be prone to acting-out behavior that may evidence to support any of the remaining answer choices.
nursing diagnoses may apply to the client with mania; however, 18. Answer: D. Ensure an unbroken chain of evidence.
Options A, B, and C: All of the remaining nursing order to ensure that the prosecution of the perpetrator can
diagnoses may apply to the client with mania; however, the occur.
15. Answer: C. Rationalization the clients privacy and identify the extent of an injury. However,
Rationalization is the defense mechanism that involves offering guidelines for preserving evidence.
excuses for maladaptive behavior. The client is defending his Option C: Identifying the assailant is the job of law
substance abuse by providing reasons related to life stressors. enforcement, not the nurse.
Options A, B, and D: None of the remaining defense Socioeconomic status is not a reliable predictor of abuse in the
mechanisms involves making excuses for behaviors. home so that it would be the least important consideration in
tolerance disregard for the rights of others Options A and B: The availability of appropriate
Physical aggressiveness, low-stress tolerance, and a disregard to intervene on the clients behalf are important factors when
for the rights of others are common behaviors in clients with making safety decisions.
as balancing a checkbook) would be the first cognitive deficit to he can meet his present needs.
occur.
24. Answer: D. Returns to his previous level of functioning.
problems with relating to family members, and difficulty Crisis intervention is based on the idea that a crisis is a
remembering ones own name are all areas of cognitive decline disturbance in homeostasis (steady state). The goal is to help
that occur later in the disease process. the client return to a previous level of equilibrium in functioning.
21. Answer: C. Reduce environmental stimuli to redirect Options A, B, and C: The remaining answer choices
the clients attention. are not considered the primary outcome of crisis intervention,
of labile mood, which can best be handled by decreasing a 25. Answer: B. Initiation phase
Option A: The client with Alzheimers disease loses phase in group therapy. Group members are more self-reliant
the cognitive ability to respond to either humor or logic. during the working and termination phases.
understand.
As the group progresses into the working phase, group
Option D: The client lacks any insight into his or her
members assume more responsibility for the group. The leader
own behavior and therefore will be unaware of any causative
becomes more of a facilitator. Comments about behavior in a
factors.
group are indicators that the group is active and involved.
Alzheimers disease. The use of diuretics would cause sodium and water excretion,
issues and problems. Open discussion of thoughts and feeling symptoms are contraindicated because they will increase the
is healthy, and parental disagreement should not cause system sympathomimetic effects of MAOIs, possibly causing a
Options A, B, and C: The remaining answer choices Options A, C, and D: None of the remaining
are life transitions that are expected to increase family stress. medications will increase the sympathomimetic response and,
which, when taken with an MAOI, can precipitate a Urinary retention is a common anticholinergic side effect of
hypertensive crisis. psychotic medications, and the client with benign prostatic
contain significant amounts of tyramine and, therefore, are not Options A and B: Adding fiber to ones diet and
Option A: If the client had taken the drug previously, Coffee contains caffeine, which has a stimulating effect on the
the nurse would also need to assess the skin color and sclera central nervous system that will counteract the effect of the
for signs of jaundice, a possible drug side affect; however, antianxiety medication oxazepam. None of the remaining foods
based on the information given here, there is no evidence that is contraindicated.
the client has received chlorpromazine before.
Option D: Although the drug can cause urine 35. Answer: B. Help members maintain sobriety.
The onset of action of the SSRI antidepressant paroxetine answer choices may be an outcome of attendance at
occurs around 3 to 4 weeks after drug therapy begins. Alcoholics Anonymous, the primary purpose is directed toward
Therefore, a client will seldom notice improvement before this sobriety of members.
assume responsibility for themselves, to learn how to respect however, other symptoms are necessary to establish this
manner.
40. Answer: D. Short words and simple sentences
may be outcomes of psychiatric treatment, but the use of a Short words and simple sentence minimize client confusion
37. Answer: A, D, C, B, then E. confusion in a client with short attention span and difficulty with
comprehension.
The nurse should remain with the client to provide support and Option B: Although pictures and gestures may be
promote safety. Reducing external stimuli, including dimming helpful, they would not substitute for verbal communication.
Encouraging the client to use slow, deep breathing will help 41. Answer: D. Fills in memory gaps with fantasy.
this can only be accomplished when the clients panic has Maintaining a calm approach when intervening with an agitated
dissipated and he is better able to focus. client is extremely important.
38. Answer: C. 0.5 Option A: Telling the client firmly that it is time to get
The initial, most basic assessment of a client with cognitive Option D: Sedation should be avoided, if possible,
impairment involves determining his level of orientation because it will interfere with CNS functioning and may
Options A and D: The nurse may also assess for 43. Answer: C. Sundowning
statements require a higher level of cognitive ability than can information is asking the family directly who they consider to be
45. Answer: C. The familys perception of the current Options B, C, and D: The question asked by the nurse
problem would not elicit information about the familys ethnicity or
and the system as a whole. Each member of the family has 48. Answer: B. Development of autonomy within the family
system and the nurse would be interested in the data. Options Differentiation is the process of becoming an individual
A and D: The childs performance in school and the teachers developing autonomy while staying in contact with the family
The parents are feeling responsible and this inappropriate self- Option D: Maintenance of system continuity or
blame can be limited by supplying them with the facts about the equilibrium is homeostasis.
reinforce their feelings of guilt. The nurse who wishes to be helpful to the entire family must
Option C: Support groups are useful; however, the remain neutral. Taking sides in a conflict situation in a family
nurse needs to handle the parents self-blame directly instead will not encourage negotiation, which is important for problem
more realistic rules or the adolescent to comply with parental parents is an example of how enmeshment affects
rules does not give the family an opportunity to try to resolve development in many cases, a child who develops anorexia
problems on their own. nervosa exerts control only in the area of eating behavior.
50. Answer: C. Enmeshment Options A, B, and D: The remaining options are not