Immediately after electroconvulsive therapy, in which position should the a nurse place the client?
On his or her side to prevent aspiration
The client confides that they fear they will lose their job as an accountant if this is known by people outside of the clinic. What response by the nurse would be most therapeutic?
Your medical record is protected by HIPPA, but we do need to disscuss your plans for the future
A 45 year old male is admitted to the emergency department after a fall from a ladder in which he hit his head approximately 2 hours ago. He has no pervious confusion nor history of drug use. The nurse asses for further symptoms of which problem?
Delirium related to potential head injury
In facilitating a group session on crisis management the nurse identifies which factor as significant in how an individual will manage a stressful situation?
the availability of adequate coping mechanisms
the individual's perception of the event
the availability of situation support
In the client with anger management issues the nurse knows to implement which intervention first to possibly prevent violence if identified in time?
Observe client for escalation of anger such as clenched teeth, tense posture, or defiant affect
The nurse getting report on a new client diagnosed with advanced Neurological disorder notices frequent episodes of agitation documented. What can the nurse do to limited this behavior before resorting to medication?
Maintain an environment of low stimulus
The nurse is caring for a client that has recently experienced a dramatic event. Which nursing diagnosis should deserve the priority attention?
Fear/crisis related to real or perceived threat to well being
In developing a care plan for a client that uses anger inappropriately which of the following interventions will assist the client to recognize anger in self and take responsibility before losing control?
Have client keep a diary of angry thoughts, what triggered them, and how they were handled.
An acquaintance the nurse sees at a local civic group they both belong to confides that he just cannot take care of his father any longer. He says, "I know I said I would never put him in a home, but he is ruining my marriage, my sleep, my productivity at work. I don't know what to do." Which nursing diagnosis does the nurse potentially recognize?
Caregiver stress/overload
The client's daughter is distraught that her mother is not remembering the names of her children and grandchildren some visits. She asks what she can do to help her hang on to those memories longer. The nurse's BEST response in giving the daughter something to do would be?
"Why don't we place some photographs around the room with names on them?"
Which term BEST describes an elderly individual recently diagnosed with depression that has experienced the loss of most of his peer group?
Bereavement Overload
Which are common behaviors in a client diagnosed with neurocognitive disorder that contribute to the diagnosis of Risk for Falls? Select all that apply.
wandering, poor coordination, misinterpretation of the environment
The nurse is conducting a one on one session with a newly admitted client in a private room. What should the nurse remember to do for safety?
Sit close to the exit from the room.
Crisis intervention helps the patient do which of the following?
Find solutions to an immediate and overwhelming problem
In a child whose assigned gender at birth is female which of the following indicators could contribute to the diagnosis of gender dysphoria?
A strong preference for toys, games, and activities traditionally labeled masculine
Which technique could the nurse utilize in a group: setting that is a form of behavior therapy?
Receiving a token or candy when displaying positive behavior.
The 78-year-old female client who is 1 day postop right hip repair is confused and does not recognize her family members. The son asks the nurse, "What is going on? She was fine before she fell." Which statement is the nurse's best response?
"She may be experiencing delirium due to the trauma, which is reversible with time."
A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner?
'I know that it was not my fault."
In a child diagnosed with Gender Dysphoria which nursing diagnòsis will cause the child the most issues in social situations?
Impaired social interaction
Which statement should indicate to a nurse that an individual is experiencing a delusion of grandeur?
The Queen of England is my mother in law"
The client diagnosed with bipolar disorder is discharged home with a goal of self-care. Which intervention should the nurse discuss with the client's significant other?
Explain the need to protect access to credit cards by the client.
A 20-year-old male presents to the community health center accompanied by his girlfriend. He is euphoric, talks rapidly, and states he feels he can become president of the United States. The girlfriend adds he has only been sleeping 2 hours per night. What nursing diagnosis will the nurse include on the plan of care as priority?
Risk for injury
What is the key characteristic with borderline personality disorder?
Frequent fluxuation in mood in a short period of time.
The nurse is caring for a client with antisocial personality disorder. The client tells the nurse he will not be making his bed this morning because he has a visitor and he needs the time to get ready. What is the nurse's best response?
"All clients must tidy their room each morning. That is one of the rules of the unit."
The client presents with an almost constant state of crisis and exhibits the following: manipulation, self-destructive behaviors, impulsivity, and clinging and distancing. Which personality disorder are these characteristics of?
Borderline personality disorder
A client diagnosed with schizophrenia states, "Look, color, hate me, get away, yes, yes." Which is an appropriate charting entry to describe this client's statement?
"The client is verbalizing a word salad."
A client diagnosed with schizophrenia exhibits a flat affect, apathy, and volition. Which medication type should a nurse expect a physician to order to address these symptoms?
An atypical anti-psychotic to treat these negative symptoms.
During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption?
Delusions of influence
A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of "making observations"?
"I notice that you are talking to someone who I do not see."
A client diagnosed with bipolar is experiencing a severe depressive episode. Which client symptom would require PRIORITY nursing intervention?
The client states, "There is no reason to go on when you feel this depressed."
A nursing instructor is teaching about bipolar disorders. Which statement differentiates the symptoms of a manic episode from a hypomanic episode?
During a manic episode, there is a marked impairment in social or occupational functioning; these symptoms are absent in hypomania.
A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client?
Do not increase or decrease dietary sodium intake.
A family reports the client diagnosed with bipolar disorder as sleeping 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which client response would the nurse expect?
Disorganized thinking and the inability to remain seated.
A client diagnosed with bipolar I disorder and experiencing a manic episode is newly admitted to the in-patient psychiatric unit. Which nursing diagnosis is PRIORITY at this time?
Risk for violence: other directed R/T poor impulse control
Although symptoms of schizophrenia occur at various times in the life span, what client would be at highest risk for diagnosis?
20-year-old man
When assessing a client who is manifesting symptoms of mania, what question by the nurse would be most helpful in collecting data about the client's condition?
"What kind of activities have you been participating in lately?"
The nurse is caring for a newly admitted client in an acute manic state on an inpatient psychiatric unit. What intervention is the highest priority?
Keep the client in a quiet, non-stimulating environment.
The client diagnosed with bipolar disorder is prescribed an anticonvulsant for mania. Which medication is the client likely prescribed?
Divalproex
The nurse notices a new speech pattern by the client admitted with schizophrenia. The client says, "My name is Terry and I want to marry. Don't carry that load of berries." Which will the nurse document?
Clang associations
The client presents with symptoms of anorexia nervosa. Which of the following does the nurse expect to see? Select all that apply.
Thinning of the hair
Hypotension