Reason: The goal of a therapeutic relationship is to enhance the personal growth of the client. This is achieved by helping clients explore problem-solving techniques and develop coping skills. Giving advice, exchanging personal information, and striving to meet the
personal needs and special desires of the client are characteristic of social relationships. Discussing the client’s feelings with family members is a breach of
confidentiality, unless previously approved by the client.
2.Answer a,c,e,f
Reason: Immediately admitting a rape victim to the treatment area may help her feel cared for and safe. Allowing a third party to remain with her, if requested,also increases her feeling of safety. “What” questions help to clarify events in a nonjudgmental way. At a
time of great distress, the nurse should pace the interview
and examination according to the client’s level of comfort. Touching a client who has recently been assaulted may increase her anxiety. The nurse should wait for the client to initiate contact or ask permission prior to initiating physical contact
3.Answer a,e,f
Reason: Feelings of displacement or directing his anger toward the nurse need to be identified and understood by the client before the nurse can help guide him to choose appropriate actions. Avoiding the client or having him direct anger at another person is inappropriate.
Approaching the client in a calm manner and offering to assist in the problem-solving process allows
the client to identify needs that aren’t being met and
explore constructive ways of dealing with his anger.
4.Answer b,e
Reason: ECT is used to treat acute depressive illnesses in an attempt to rapidly reverse a life-threatening situation, such as disturbing delusions, agitation, or attempted
suicide. It’s also used when the client can’t tolerate tricyclic antidepressants, since other medication regimens for depression can take weeks to become
effective. ECT usually isn’t indicated for situational
depression caused by intense stress. Clients with dementia aren’t given ECT because ECT may further
exacerbate cognitive impairment. The decision to
use ECT isn’t based on where the client lives.
5.Answer a,c,e,f
Reason: A client will test the nurse-client relationship by acting in ways to control the relationship or to elicit an emotional response from the nurse. Examples
of the testing behavior include speaking about things that will shock the nurse, violating personal space, requesting personal information, and placing the nurse
in the role of parent. Dressing in a flamboyant or seductive
manner demonstrates a lack of rules or expected behaviors; this is a violation of boundary setting.
A contract is used to develop or negotiate an
agreement between the nurse and the client to achieve a mutual goal.
6.Answer a,b,d
Reason: A person who is admitted to a psychiatric hospital may voluntarily sign out of the hospital unless the health care team determines that the person is
harmful to himself or others. The health care team evaluates the client’s condition before discharge. If there’s reason to believe that the client may be harmful
to himself or others, a hearing can be held to determine if the admission status should be changed from voluntary to involuntary. The client still has rights after
committing himself to a psychiatric unit. The client doesn’t need a lawyer to leave the hospital. A court hearing is held only if the client may pose a threat to
himself or others and requires further treatment.
7.Answer a,c,d,f
Reason: Acknowledging the addiction’s effects on the family and discussing its financial impact will help the client to identify personal strengths in dealing with
addiction and strengthen the therapeutic relationship in the process. Discussing the family history of addiction and expressing uncertainty about what topics to address with the nurse typically happen during the introductory phase of a nurse-client relationship.
8.Answer a,c,f
Reason: Sleep and appetite disturbances and suicidal thoughts can appear in clients with dysthymia or
major depressive disorders. Onset of symptoms are gradual and may appear over weeks or months. Delusions and other psychotic symptoms may occur in major
depression but don’t occur in dysthymia, a milder and more chronic mood disorder. Episodes of depression occurring solely in the winter are indicative of seasonal
affective disorder.
9.Answer b,c,4,f
Reason: Impulsive behavior, overwhelming guilt,chronic illness, and repressed anger are factors that
contribute to suicide potential. Psychomotor retardation and decreased physical activity are symptoms of depression, but they don’t typically lead to suicide because
the client doesn’t have the energy and cognitive abilities to harm himself.
10.Answer b,e,f
Reason: Client education should cover the signs and symptoms of drug toxicity, the need to report
them to the physician, and the need for regular monitoring of drug blood levels. The nurse should also inform the client that mood changes may not be apparent for 7 to 21 days after treatment is initiated. Lithium doesn’t have addictive properties and doesn’t cause tardive dyskinesia. Tyramine is a potential concern to clients who are also taking monoamine-oxidase inhibitors.
11.Answer a,d,e,f
Reason: Dementia is characterized by a slow onset of symptoms, which makes it difficult to determine
when symptoms first occurred. It progresses to noticeable changes in the individual’s personality and impaired ability to pay attention to other people. Sadness,
apathy, and pessimism are symptoms of depression.
12.Answer C
Reason: A situational crisis results from a specific event in the life of a person who is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks.
13.Answer C
Reason: Resolving grief and having increased energy and activity convey good mental health, indicating that counseling is not necessary at this time. Taking an antidepressant or having less energy and involvement with grandchildren reflects possible depression and the need for counseling. Wanting to be with her dead husband suggests possible suicidal ideation that warrants serious further assessment and counseling.
14.Answer C
Reason: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.
15.Answer A
Reason: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences. Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.
16.Answer A
Reason: Staff members sometimes are the recipients of a client's angry behavior because they are safe targets and are available for attack. The display of anger is rarely intended to be personal. Such behavior is not necessarily a sign of serious pathology but must be weighed in conjunction with other behaviors. An angry outburst is not an attack on a primary care provider's skills. While not necessarily pathologic, the client's behavior isn't a sign that his condition is improving.
17.Answer B
Reason: During a period of crisis, the major goal is to resolve the immediate problem, with hopes of getting the individual to the level of functioning that existed before the crisis or to a higher level of functioning. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. The client's anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment; it isn't a major goal.
18.Answer B
Reason: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.
19.Answer B
Reason: Helping the client control his weight is the most appropriate approach. The nurse's contradiction of the client's complaint is inappropriate. Most atypical antipsychotics cause weight gain and are not a solution to the weight gain. There is little evidence that weight gain from taking olanzapine decreases with time.
20.Answer D
Reason: Significant orthostatic hypotension is associated with risperidone (Risperdal) therapy. The nurse should monitor the client's blood pressure sitting and standing and teach the client interventions to manage this adverse effect to prevent risk of injury. Although insomnia, headache, and anxiety are possible adverse effects of risperidone therapy, they are of less immediate concern than orthostatic hypotension.
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