Final Assessment. Psychosocial Integrity

A client diagnosed with schizophrenia tells the nurse. “There are voices outside the window telling me what to do all the time. Can you hear them? What should I tell them?” How should the nurse respond initially?

A client hospitalized in a mental health unit is restrained after becoming extremely violent. Which finding indicates to the nurse that the client can be removed from the restraints?

A client experienced the sudden onset of blindness, but extensive testing revealed no organic reason that the client could not see. The nurse later learned that the blindness developed after the client witnessed a fire at a neighboring house in which the family of three died. Which problem should the nurse suspect?

A client hospitalized with schizophrenia says to the nurse, “Get your goat. Go out and vote. Don’t be a cut throat. Row your boat.” How should the nurse document the client’s behavior?

While conducting an initial assessment of an infant, a home health nurse notices that the infant is wearing a soiled piece of braided yarn around the neck. Which action by the nurse is most appropriate?

A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.

An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. During the admission assessment, which behaviors would be characterized as compulsions? Select all that apply.

A rehabilitation nurse is caring for a young client recovering from a motor vehicle accident in which he lost both legs. The client states, “I will never be able to work again or live a normal life.” Which responses by the nurse would be considered therapeutic? Select all that apply.

A nurse is caring for a client diagnosed with persistent depressive disorder. Which defining characteristics are associated with this disorder? Select all that apply.

The charge nurse is caring for clients in an acute care psychiatric unit. Which client would be most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)?

The male client admitted to the medical unit after a motor vehicle accident (MVA) admits using heroin. The unlicensed assistive personnel (UAP) tells the RN the client is really agitated and anxious and has slurred speech. Which intervention should the nurse implement first?

A client whose spouse recently died is experiencing dysfunctional grieving. Which intervention has priority in the plan of care?

A client who recently witnessed a murder says, “I feel like I’m losing my mind. I keep hearing the gunshots and seeing the victim lying on the ground.” In light of the client’s statement, the nurse should:

A client with bipolar disorder has been hospitalized for 4 days. Today in group therapy the client offered helpful suggestions in regard to another client’s problem. The nurse concludes that the client’s behavior is representative of:

A nurse has developed a therapeutic relationship with a client who has an addiction disorder. Which client behaviors would indicate that the therapeutic interaction is in the working phase? Select all that apply.

A client who is hallucinating fearfully says to the nurse, “Please tell that demon to get out.” How should the nurse respond to the client?

A nurse cares for a severely depressed client who is mute. Which comment by the nurse to the client is appropriate?

A client says to the nurse, “Even though my husband and I keep telling them we don’t want to have children, our parents are pressuring us to ‘start a family.’ What should we say to them?” Which of the following responses by the nurse is therapeutic?

The mental health worker (MHW) reports to the RN psychiatric nurse that two clients were kissing each other while watching the movie in the lobby area. Which action should the nurse implement?

A client with delirium suddenly picks up a can of soda from the meal tray and threatens to throw it at the nurse. How should the nurse respond?

A client with obsessive-compulsive disorder is hospitalized because his ritualistic behaviors have become so time-consuming that the client is unable to maintain employment. The initial priority nursing intervention is to:

A client says to the nurse, “I’m divorced and my children live in other parts of the country. They never visit or phone me. I feel so lonely. No one would notice if I were gone.” The nurse should make which response to the client?

A client is transitioning to a less intensive level of outpatient treatment for addiction. The nurse concludes the client is most at risk for relapse after the client makes a statement reflecting which theme?

A client with a personality disorder will begin recreational therapy as a component of the treatment plan. This treatment modality is most helpful for clients who:

What statement made by the mother of a recovering compulsive Internet user would indicate the need for more teaching?

Which of the following approaches would be best for the nurse who is communicating with the cognitively impaired client? Select all that apply.

A client tells the nurse, “I did my hair just like my favorite math teacher wears hers. I hope I can be a good teacher, too.” Which defense mechanism is the client using?

A client with a terminal illness states, “If I could only live until I can walk my daughter down the aisle at her wedding, I will donate all of my money to research.” The nurse reports that the client is in which phase of the grief process?

A depressed client tells the nurse, “I’m powerless, and I’m not worthy of having friends. Sometimes I take too many pills.” The nurse’s priority in planning care for this client is:

A client with depression says to the nurse, “My child is dead, and I don’t want to live anymore.” Which comment by the nurse is therapeutic?

A home care nurse visits a depressed older adult client in whom type 2 diabetes mellitus was recently diagnosed. As the nurse teaches him about insulin injections, the client says, “I don’t think I’ll ever learn to stick this needle in myself.” Which response by the nurse is therapeutic?

The RN is caring for children in a psychiatric unit. Which client requires immediate intervention by the psychiatric nurse?

The nurse is working in an outpatient mental health clinic and returning phone calls. Which client should the psychiatric nurse call first?

Which client should the psychiatric clinic nurse assess first?

The nurse is caring for a client with severe depression. In which conditions would the nurse anticipate the use of electroconvulsive therapy (ECT) as an option? Select all that apply.

A client with a medical illness tells the nurse that going to church is not a priority. Based on this information, what should the nurse do at this time?