A nurse is contributing to the plan of care for a client who has dementia. Which of the following actions should the nurse include in the plan of care? - ANS Provide a consistent daily routine
A consistent daily routine is appropriate for the care of a client who has dementia.
A nurse i...
A nurse is contributing to the plan of care for a client who has dementia. Which of the following
actions should the nurse include in the plan of care? - ANS Provide a consistent daily
routine
A consistent daily routine is appropriate for the care of a client who has dementia.
A nurse in a mental health clinic is attempting to develop trust in the nurse-client relationship.
Which of the following techniques is appropriate? - ANS The nurse uses consistency in
approaching the client
Using a consistent approach to client care promotes trust in the nurse-client relationship.
A nurse is caring for a client who is taking fluphenazine for schizophrenia. Which of the following
findings is the nurse's priority? - ANS Tachycardia
Tachycardia indicates that this client is at greatest risk for anticholinergic toxicity: therefore, this
is the nurse's priority finding. The nurse should withhold the client's next dose of fluphenazine
and contact the provider.
A nurse is collecting data from a client who has hypomania. Which of the following findings
should the nurse expect? - ANS euphoria
A client experiencing hypomania often experiences a sense of euphoria
A nurse is caring for a client on a psychiatric unit. After nine electroconvulsive therapy (ECT)
treatments, the client reports less depression but short-term memory loss. Which of the
following is the appropriate nursing action? - ANS Explain that this memory loss is
temporary, and the client's memory will return to normal after several weeks.
Short-term memory problems are temporary side effects of ECT treatment. While the duration of
these memory problems may differ among individuals, it often resolves within several weeks.
A provider tells a client who has an anterior cruciate ligament that he may not play football for
the remainder of the season. The client yells that the provider doesn't know what he is talking
about and kicks a chair. Which of the following defense mechanisms is the client
demonstrating? - ANS Displacement
The client is demonstrating displacement when he shifts feelings about an object, person, or
situation to another less threatening object, person, or situation. The client transferred his
emotional reaction about the injury and inability to play to the provider and to the chair.
, A nurse is caring for a client during admission to an alcohol treatment center. When working
with this client, which of the following approaches is appropriate? - ANS Maintain a
nonjudgmental attitude.
When working with clients who have an addictive disorder it is important that the nurse remain
nonjudgmental.
As part of the plan of care for a client with borderline personality disorder. the nurse reviews the
day's schedule with him each morning. While doing so, the client states. "Why don't you shut up
already! I can read it myself, you know!" Which of the following is an appropriate nursing
response? - ANS " don't like it when you address me with that tone of voice."
Borderline personality disorder (BPD) is described as an emotionally unstable personality.
Clients with BPD may show a wide range of impulsive behaviors in all aspects of their lives,
including self-destructive behaviors. The client in this situation has overstepped a limit by
addressing the nurse in a less-than-respectful tone of voice. This therapeutic response calls to
the client's attention the inappropriate behavior and sets appropriate limits for further
communication
A nurse is caring for a client who has schizophrenia and taking haloperidol. The nurse observes
that the client has developed a stooped posture and shuffling gait. The nurse should document
these findings as which of the following extrapyramidal side effects of haloperidol? - ANS
Pseudoparkinsonism
Pseudoparkinsonism is an extrapyramidal side effect that includes findings such as a stooped
posture, shuffling gait, tremor, drooling, and a mask-line facial expression.
A nurse is caring for a 20-year-old college student who reports severe epigastric distress, and a
2-year history of bulimia. She tells the nurse, "I know my eating binges and vomiting are not
normal, but I cannot do anything about them." Which of the following is a therapeutic response
by the nurse? - ANS "It seems like you are feeling helpless about this behavior."
effectively.
The nurse is responding to the feelings the client has expressed. Clarifying feelings begins the
process of exploring how to deal with them more
A nurse is reinforcing teaching with a client who is to begin taking paroxetine. Which of the
following statements by the client indicates an understanding of the teaching? - ANS -I
MIGHT NOT FEEL LIKE EATING AS MUCH
Anorexia and a decreased appetite are adverse effects of paroxetine.
A nurse is assisting with the admission of a client who has a suspected cognitive disorder.
Which of the following resources should be included as part of the data collection? - ANS
Mini-Mental State Examination (MMSE)
The use of a mental status questionnaire assists in identifying deterioration in mental status and
brain damage which are findings associated with cognitive disorders.
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