- B. Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games can stimulate aggression and increase psychomotor activity.
- D. Change in appetite is one of the major symptoms of depression. Reporting to the psychiatrist and nutritionist is to some degree correct but lacks the method as to how one would increase food intake.
- D. A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Option 3 is a forceful and absolute approach.
- D. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences for the client that are challenging but will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1 and 3 give advice and devalue the client’s feelings.
- A. major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client’s psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person’s capacity to deal with the demands of life. Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option 1 is correct.
- B. The exact cause of depression is not known but is believed to be related to biochemical disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatment for the disease process.
- C. Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominately elevated, expansive, or irritable. All options reflect a client’s possible symptomatology. Option 3, however, clearly presents a problem that compromises one’s physiological integrity and needs to be addressed immediately.
- B. A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow use of excess energy yet not endanger others during the process. Options 1, 3, and 4 are relatively sedate activities that require concentration, a quality that is lacking in the manic state. Such activities lead to increased frustration and anxiety for the client. Tetherball is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy that the client is experiencing.
- D. The nurse encourages the client and the family to verbalize fears and concerns. The other options avoid dealing with concerns and are blocks to communication.
- A. The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to Haldol. Option 2 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse.
- A, D, and E. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a non-punishment manner; and assisting the client in identifying strengths and in testing out alternative behaviors for obtaining needs. Enforcing rules and informing the client that he or she will not be allowed to attend group therapy sessions is a violation of the client’s rights. Ensuring the client knows that he or she is not in charge of the nursing unit is inappropriate, power struggles need to be avoided.
- A. If a client with severe anxiety is left alone; the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
- B. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Elimination anxiety from life is impossible.
- A. Some of the symptoms associated with delirium tremors typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in LOC, agitation, fever, and delusions.
- B. The most helpful response is one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.
- B. Al-Anon support groups are protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavior changes. Option 2 is the most healthy response because is exemplifies and understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control.
- C. In the defense mechanism of denial the person denies reality. Option 1 identifies denial. In option 2 the client is relying heavily on others, and the client’s focus of control is external. In option 4 the client is concrete and procedure oriented; again the client identifies that “Nothing will go wrong that way” if the client follows all the directions. In option 3 the client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in that statement.
- D. A nurse can be charged with false imprisonment if a client is made to believe wrongfully that the client cannot leave the hospital. Most health care facilities have documents that the client is asked to sign that relate to the client’s responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold him against his will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise.
- A, D, and E. When the client is experiencing withdrawal of alcohol, the priority of care is to prevent the client from harming himself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained.
- B. The client must define the experience as traumatic to realize the situation wasn’t under his personal control. Encouraging the client to verbalize the experience without first addressing the denial isn’t a useful strategy. The client can move on with life only after acknowledging the trauma and processing the experience. Acknowledgement of the actual trauma and verbalization of the event should come before the acceptance of feelings.
- A. Denial can act as a protective response. The client tends to be overwhelmed and disorganized by the trauma, not indifferent to it. Perfectionism is more commonly seen in clients with eating disorders, not in clients with PTSD. Clients who have had a severe trauma often experience an inability to trust others.
- B. To decrease stimulation, the nurse should attempt to redirect and focus the client’s communication, not allow the client to talk about different topics. By addressing the client in a light and joking manner, the conversation may contribute to the client’s feeling out of control. For a manic client, it’s best to ask closed questions because open-minded questions may enable the client to talk endlessly, again possibly contributing to the client’s feeling out of control.
- D. Any time the level of sodium increases, such as with a change in the dietary intake, the levels of lithium will decrease.
- D. For a client thinking about suicide on a daily basis, inpatient care would be the best intervention. Although a no-suicide contract is an important strategy, this client needs additional care. The client needs a more intensive level of care than weekly outpatient therapy. Immediate intervention is paramount, not a second psychiatric opinion.
- D. A sleep ritual or nighttime routine helps the client to relax and prepare for sleep. Obtaining sleep medication is a temporary solution. Working on problem solving may excite the client rather than tire him. Exercise before retiring is inappropriate.
Answers for Drug Abuse NCLEX Questions
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