Which nursing action is most appropriate when trying to diffuse a client’s impending violent behavior? A. Place the client in seclusion. B. Leaving the client alone until he can talk about his feelings. C. Involving the client in a quiet activity to divert attention. D. Helping the client identify and express feelings of anxiety and anger.
Correct Answer: D. Helping the client identify and express feelings of anxiety and anger In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statements as “What happened to get you this angry?” may help the client verbalize feelings rather than act on them. Frequently assess client’s behavior for signs of increased agitation and hyperactivity. Early detection and intervention of escalating mania will prevent the possibility of harm to self or others, and decrease the need for seclusions. Option A: Alert staff if a potential for seclusion appears imminent. Usual priority of interventions would be: firmly setting limits; chemical restraints (tranquilizers); or seclusion. If nursing interventions (quiet environment and firm limit setting) and chemical restraints (tranquilizers–e.g., haloperidol [Haldol]) have not helped dampen escalating manic behaviors, then seclusion might be warranted. Option B: Maintain a consistent approach, employ consistent expectations, and provide a structured environment. Clear and consistent limits and expectations minimize potential for client’s manipulation of staff. Remain neutral as possible; Do not argue with the client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania. Option C: Redirect agitation and potentially violent behaviors with physical outlets in an area of low stimulation (e.g., punching bag); can help to relieve pent-up hostility and relieve muscle tension. Decrease environmental stimuli (e.g., by providing a calming environment or assigning a private room); helps decrease escalation of anxiety and manic symptoms.
Psychiatric Nursing (NCLEX Exams)
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Text Mode – Text version of the exam 1. Francis who is addicted to cocaine withdraws from the drug. Nurse Ron should expect to observe:
2. Nurse John is aware that a serious effect of inhaling cocaine is?
3. A tentative diagnosis of opiate addiction, Nurse Candy should assess a recently hospitalized client for signs of opiate withdrawal. These signs would include:
4. A 48 year old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client’s wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for:
5. Before helping a male client who has been sexually assaulted, nurse Maureen should recognize that the rapist is motivated by feelings of:
6. When working with children who have been sexually abused by a family member it is important for the nurse to understand that these victims usually are overwhelmed with feelings of:
7. Joy who has just experienced her second spontaneous abortion expresses anger towards her physician, the hospital and the “rotten nursing care”. When assessing the situation, the nurse recognizes that the client may be using the coping mechanism of:
8. The most critical factor for nurse Linda to determine during crisis intervention would be the client’s:
9. Nurse Trish suggests a crisis intervention group to a client experiencing a developmental crisis. These groups are successful because the:
10. Nurse Ronald could evaluate that the staff’s approach to setting limits for a demanding, angry client was effective if the client:
11. Nurse John is aware that the therapy that has the highest success rate for people with phobias would be:
12. When nurse Hazel considers a client’s placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client’s:
13. In the diagnosis of a possible pervasive developmental autistic disorder. The nurse would find it most unusual for a 3 year old child to demonstrate:
14. Malou with schizophrenia tells Nurse Melinda, “My intestines are rotted from worms chewing on them.” This statement indicates a:
15. Andy is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. Nurse Hilary should expects the assessment to reveal:
16. PROPRANOLOL (Inderal) is used in the mental health setting to manage which of the following conditions?
17. Which medication can control the extra pyramidal effects associated with antipsychotic agents?
18. Which of the following statements should be included when teaching clients about monoamine oxidase inhibitor (MAOI) antidepressants?
19. Kris periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, Kris may experience:
20. Initial interventions for Marco with acute anxiety include all except which of the following?
21. Nurse Jessie is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
22. When performing a physical examination on a female anxious client, nurse Nelli would expect to find which of the following effects produced by the parasympathetic system?
23. Which of the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD)?
24. Tony with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobia include:
25. Which nursing action is most appropriate when trying to diffuse a client’s impending violent behavior?
26. Rosana is in the second stage of Alzheimer’s disease who appears to be in pain. Which question by Nurse Jenny would best elicit information about the pain?
27. Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for:
28. Jose who is receiving monoamine oxidase inhibitor antidepressant should avoid tyramine, a compound found in which of the following foods?
29. Erlinda, age 85, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find:
30. Barbara with bipolar disorder is being treated with lithium for the first time. Nurse Clint should observe the client for which common adverse effect of lithium?
31. Nurse Fred is assessing a client who has just been admitted to the ER department. Which signs would suggest an overdose of an antianxiety agent?
32. Discharge instructions for a male client receiving tricyclic antidepressants include which of the following information?
33. Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?
34. A client refuses to remain on psychotropic medications after discharge from an inpatient psychiatric unit. Which information should the community health nurse assess first during the initial follow-up with this client?
35. The nurse understands that the therapeutic effects of typical antipsychotic medications are associated with which neurotransmitter change?
36. Which of the following best explains why tricyclic antidepressants are used with caution in elderly patients?
37. A client with depressive symptoms is given prescribed medications and talks with his therapist about his belief that he is worthless and unable to cope with life. Psychiatric care in this treatment plan is based on which framework?
38. A nurse who explains that a client’s psychotic behavior is unconsciously motivated understands that the client’s disordered behavior arises from which of the following?
39. A client with depression has been hospitalized for treatment after taking a leave of absence from work. The client’s employer expects the client to return to work following inpatient treatment. The client tells the nurse, “I’m no good. I’m a failure”. According to cognitive theory, these statements reflect:
40. The nurse describes a client as anxious. Which of the following statement about anxiety is true?
41. A client with a phobic disorder is treated by systematic desensitization. The nurse understands that this approach will do which of the following?
42. Which client outcome would best indicate successful treatment for a client with an antisocial personality disorder?
43. The nurse is caring for a client with an autoimmune disorder at a medical clinic, where alternative medicine is used as an adjunct to traditional therapies. Which information should the nurse teach the client to help foster a sense of control over his symptoms?
44. Which of the following is the most distinguishing feature of a client with an antisocial personality disorder?
45. Which nursing diagnosis is most appropriate for a client with anorexia nervosa who expresses feelings of guilt about not meeting family expectations?
46. A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful?
47. A client with dysthymic disorder reports to a nurse that his life is hopeless and will never improve in the future. How can the nurse best respond using a cognitive approach?
48. A client with major depression has not verbalized problem areas to staff or peers since admission to a psychiatric unit. Which activity should the nurse recommend to help this client express himself?
49. The home health psychiatric nurse visits a client with chronic schizophrenia who was recently discharged after a prolong stay in a state hospital. The client lives in a boarding home, reports no family involvement, and has little social interaction. The nurse plan to refer the client to a day treatment program in order to help him with:
50. Which activity would be most appropriate for a severely withdrawn client?
Answers and Rationales
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