PrepU Psych Exam 1

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the nurse's primary commitment is to the health, safety and welfare of people placed in her care, as well as to the public. This commitment is provided through evidence-based care. What does the term evidence-based care mean?
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Terms in this set (322)
What action should a nurse take when unintentionally making an inappropriate or awkward statement to a client?clarify by saying, "that wasn't what I meant to say"which intervention is focused on a goal included in Healthy People 2020 Mental Health objectives?including a depression screening in the assessment interview conducted by the staff of a group of family practitionersWhen reviewing evidence-based practice, which characteristics would the nurse most likely identify as important?it aids in clinical decision making, it applies research finding practically, it is a problem-solving approachWhen describing the historical aspects of psychiatric-mental health care, the nurse addresses the changes in thought about the cause of mental illness from 0-1000 CE. Which cause would the nurse most likely identify as the belief during this period?demonic controlWhat is the reason for the deinstitutionalization movement?view the institutionalization contributed to mental illnessA psychiatric-mental health nurse is describing the various programs offered by the local community mental health center. When explaining how these programs work, the nurse would emphasize which concept?collaborationA psychiatric-mental health nurse working in a community mental health center is reviewing information about issues facing those individuals receiving care at the center. Which issues would then nurse likely identify as emerging over the recent years?trauma experienced by military members, psychological trauma resulting from natural disasters, treatment of dementia experienced by older adultsA nurse is reading a journal article about practices involved during the moral treatment movement in psychiatric-mental health care. Which practice would most likely be included as being used during this time?asylumsWhich type of treatment was the focus of care in most community mental health centers during the time of deinstitutionalizationalcoholism, drug additionWhich item is considered the standard of care in psychiatric nursing and mental health care?evidence-based practiceA community health nurse is developing a plan to improve her community's negative attitudes about those suffering from mental illness. Which of the following would assist her in accomplishing this goal?identify myths underlying the negative attitudes in the community and prove factual knowledge about mental illnessAccording to WHO, by 2030 which mental illness is projected to be the leading burden of disease worldwide?depressionOne of the major problems facing individuals with mental illness and their families is stigma. Which is inconsistent with stigmatization?approvalA universal condition that shapes the way we think, feel and communicate refers to:mental healthA nurse is giving a presentation about preventing mental illness to college freshmen. A student asks, "What does it mean to be mentally healthy?" Which of the following potential responses by the nurse is best?"mental health is marked by productivity, fulfilling relationships, and adaptability"A nurse shows the best understanding of mental illness when defining it as the ...inability to function in a manner that manages both external and internal stressors effectivelyIn the United States, more than 57 million people have a diagnosable mental disorder in any given year. This statistic is an example of which of the following?prevalenceA nurse is orienting to a new position working the infirmary in the state penitentiary. When working with prisoners who are mentally ill, the nurse examines the nurse's own attitudes. Which beliefs should the nurse discuss with a supervisor before caring for incarcerated clients?people with mental illness are inherently violentWhich statement would a nurse integrate into an education plan for a local community group about mental illness and mental disorders?clusters of behaviors, thoughts and feelings define mental disordersWhich statement is most accurate about the Diagnostic and Statistical Manual of Mental Disorders-5?boundaries separating disorders are not absoluteWhich are examples of public stigma? (Select all that apply.)A film depicting an individual with a mental illness as dangerous and out of control. Mental health clinicians are described as being arrogant and manipulative during an interview. A television show depicting an individual with mental illness as being possessed by the devilA nursing instructor is teaching a class about stigma and using nonstigmatizing language. The instructor determines that the education was successful when the students state which of the following as an example?client with major depressionA nurse is preparing a presentation about how mental health providers are often portrayed in the media, which leads to public stigma. Which of the following descriptors would the nurse most likely include?arrogantAfter teaching a class of nursing students about mental health and mental disorders, the instructor determines that additional education is needed when the class states which of the following as reflective of mental health?mental health involves psychological well-being but not emotional well-beingWhich of the following would be associated with stigma?Disapproval Shunning StereotypingA client with a mental illness tells the nurse, "I'm just like what others say I am. I can never be normal." The nurse interprets this statement as reflecting which of the following?self-stigmaIn which of the following clients would the nurse be most likely to identify the phenomenon of label avoidance?A client who insists that his diagnosis be kept secret because of the perceived risk of "career suicide"A family member of a client diagnosed with a mental illness asks the nurse, "What is mental illness, really?" Which information would the nurse most likely integrate into the response? Select all that apply.Mental illness can cause significant distress Mental illness can interfere with a person's ability to function. Individuals suffering from mental illness may experience dissatisfaction with relationshipsA psychiatric-mental health nurse working at a community mental health center is using epidemiological data to plan the development of programs for the population in the future. Based on the nurse's knowledge associated with disease projections and the leading burden of disease, the nurse would work on developing programs for which condition?depressionA nurse is assessing a client who has come to the clinic for an evaluation. The nurse determines that the client is mentally healthy based on which finding? Select all that apply.Client talks readily about doing things with friends and family. Client describes actions used to appropriately cope with life stresses. Client verbalizes a realistic depiction of surroundings and events. Client identifies strengths and weaknesses in abilities.Samuel has been committed involuntarily to a psychiatric-mental health facility to allow time to determine an appropriate diagnosis. What is this type of involuntary commitment known as?observationalWhile performing the admission assessment of a new client, the nurse observed that the client brought a bottle of over-the-counter pain medication to the hospital. The nurse failed to document this or remove the medication from the room. Subsequently, the client experienced a serious adverse drug reaction as a result of the interaction between this drug and one of the drugs that the client was prescribed in the hospital. This nurse may be guilty of what?malpracticeA 22-year-old client has voluntarily sought treatment for an eating disorder at a rural residential facility. Despite a promising start, the client has been involved in recent conflicts with staff members and insists that the client wants to leave the facility. Staff members have refused to facilitate the client's transportation from the facility and have stated that they will not return the client's money and identification that were held when the client was admitted. Staff at the treatment facility may be guilty of false imprisonment due to what?the client voluntarily admitted for treatmentAs a result of the increasing severity of delusions and consequent unsafe behavior, a client has been admitted to a psychiatric facility and judged incompetent to make decisions. Who will now make decisions for the client?a guardian appointed by the courtWhich action is a violation of a psychiatric client's rights?Staff members confiscate letters written by a committed client that are addressed to a local newspaper.Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of what?confidentialityAll of the following are civil rights afforded to all people receiving mental health care except which of the following?right to leave the hospital when involuntarily committedWhich of the following are criteria for instituting the short-term use of restraint or seclusion? Select all that apply.The client is aggressive. The client is imminently dangerous to the self or to others. All other means of calming the client have been unsuccessful.A malpractice lawsuit was filed after a nurse restrained the client for screaming at and attempting to strike anyone who was within striking distance. The nurse followed agency procedures that were consistent with Joint Commission Standards. For which reason is this malpractice lawsuit most likely to be unsuccessful?the nurse did not breach dutyA client underwent a procedure before the nurse verified the client's signature on the consent form. The client actually did not sign the form before the procedure. If the client is dissatisfied with the outcome of the procedure and files a suit against the health care team, which kind of case can the client file?batteryDuring rounds, a client with depression is discovered to have completed a suicide attempt in the bathroom. The staff members on the inpatient psychiatric unit have been very busy and fell behind on periodic assessment for this client. The client's family decides to pursue legal action against the staff and facility. The client's family would most likely claim:malpracticeA psychiatric-mental health client has been admitted to the emergency department following an episode of psychotic behavior. The client has presented a written psychiatric advance directive (PAD) that exhaustively details many aspects of her desired care. What factor should prompt the care team to disregard the provisions of the PAD?the client had been deemed legally incompetent when she created the documentFollowing an assault, a client with mental illness has been declared unfit to stand trial. The nurse should draw what conclusion from this fact?the client can't comprehend the legal proceedingsThe nurse is caring for a client who is legally competent and who has been receiving outpatient treatment for schizophrenia. The client has been responding favorably to treatment but has now declared her intention to exclusively pursue alternative medicine. What is the nurse's most appropriate response?educate the client about the benefits of continuing the existing treatmentA nurse in the emergency department is planning for a client with mental illness to be placed in an inpatient hospitalization. Which is a condition of this type of admission?present a clear danger to self or othersA client diagnosed with depression tells the psychiatric-mental health nurse that the client wants to use an herbal supplement to treat the symptoms rather than an antidepressant. The nurse interprets this information as demonstrating which concept?self-determinismThe client just received a diagnosis of end-stage renal disease. After hearing options, the client visited a lawyer and documented what treatment is to be held in the event that the client is unable to make decisions. The nurse asks for a copy of this document for the chart. The name of this document is:living willThe nursing instructor is talking to a class of nursing students about the American's with Disabilities Act, and persons having various disabilities that have the right to education in the least restrictive environment. The nursing instructor asks the students, "what is the reason for the least restrictive environment?" Which example should the student nurse choose?unique needsThe client is brought to the hospital in a coma. The nurse understands that when a person is incapacitated, the document used to dictate the patient's written instructions for health care is called:advanced directiveWhich of the following medication classifications are used to assist clients to calm down? Select all that apply.Antianxiety medications Antipsychotics Mood stabilizersThe client has difficulty with motor coordination and walks with an unsteady gait. Of the following brain structures, which is most likely affected in the client's brain?cerebellumThe client has seasonal affective disorder (SAD), in which depression parallels the shortening of the days during fall and winter. Which is most likely affected in the client?circadian rhythmWhich is the primary role of neurotransmitters?Communicate information from one cell or cell group to anotherThe nurse is caring for a mental health client who has developed difficulty with balance and muscle tone after a car accident that involved a head injury. Based on this information, what area of the brain was most likely injured in the accident?cerebellumWhich is a major difference between the atypical antipsychotics (such as clozapine) and the typical antipsychotics (such as haloperidol)?Atypical antipsychotics block both serotonin and dopaminergic receptors.Which of the following is an inhibitory neurotransmitter?GABAA client diagnosed with a stroke is exhibiting expressive aphasia. Which area in the frontal lobe is responsible for the motor function of speech?Broca's areaA client taking an antipsychotic is exhibiting manifestations of neuroleptic malignant syndrome (NMS). Which area of the brain is involved with the increased temperature noted with NMS?hypothalamusWhich neuropeptide suppresses pain and modulates mood and stress?endorphinsA nurse is reviewing the process of neuronal transmission. The nurse demonstrates understanding of this concept by identifying which part of the neuron as carring information into the neuron from other neurons?dendriteTwo nursing students are giving a presentation on the limbic system. Which can they accurately include as actions of this brain structure?behaviorWhat part of the brain would be responsible for activities such as walking and dancing?cerebellumA client in the operating room goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is what?hypothalamusA nurse is studying the positron emission tomography (PET) report of a client with Alzheimer's disease. What findings should the nurse expect to find in the report? Select all that apply.Decreased blood flow to the brain Presence of amyloid plaques and tangles Decreased glucose metabolism in the brainA client diagnosed with bipolar disorder asks the nurse, "Why did I get this illness? I don't want to be sick." What response should the nurse provide to best answer the client's question?"We don't fully understand the cause, but mental illnesses do seem to run in families."The nurse is teaching the client with anxiety about the mechanisms of benzodiazepines. Which is increased with this medication?GABAA client has a lithium level of 1.2 mEq/L. Which intervention by the nurse is indicated?No intervention is necessary at this time.A client is seen for frequent exacerbation of schizophrenia due to nonadherence to medication regimen. The nurse should assess for which common contributor to nonadherence?The client dislikes the weight gain associated with antipsychotic therapy.A client is brought to the emergency department with reports of slurred speech, spasms, and jerky movements. The significant other shows the nurse a pill bottle and states that the client has been taking antipsychotic medications for "awhile". The nurse notices that an "improper dose" is ordered on the prescription bottle. How would the nurse explain what system is causing the movements?"Dysfunction of the extrapyramidal motor track can manifest serious neurologic symptoms including dystonia, pseudoparkinsonism, and akathisia"In which way do neurons communicate through the use of synapses?electrochemicallyDuring which phase of the nurse-client relationship does the client identify and explore specific problems?workingWhich communication technique does a nurse use in establishing trust and developing empathy?acceptanceThe nursing instructor is teaching about the importance of communication in nursing and relates it to the family. Which statement by a student nurse would indicate that the teaching has not been effective?nonverbal communication is not meaningfulWhile the nurse and client are in a therapy session, the nurse says to the client, "You become very anxious when we start talking about your drinking." Which technique is the nurse using?making an observationThe nurse is working with a client who has quit several jobs and no longer sends financial support to the client's two children living with their other parent. This behavior is in conflict with the nurse's values concerning responsible parenting. When discussing family roles with the client, the nurse shows positive regard through which statement?"How is not working right now affecting you?"A nurse and client are engaged in a discussion. The client says, "I feel really close to you. You are the only true friend I have." Which response by the nurse would be most therapeutic?"Since ours is a professional relationship, let's explore other opportunities in your life for friendship."The nurse and client are discussing an upcoming sporting event in which they both share an interest. This form of interaction has the potential to pose which threat to the nurse-client relationship?avoid the work needed for the client to reach set goalsThe client is getting ready to be discharged from the psychiatry unit. A nurse and client has just completed reviewing the client's take-home medications. The nurse is exemplifying which role during this intervention?teacherA nurse is communicating with a client who is highly anxious. During the conversation, the nurse notices that the nurse's speech is matching the fast pace of the client's speech, and the nurse's heart rate is increasing. The nurse identifies this as:empathetic linkageNurses develop empathy with their clients while gathering information about the client. Which of the following hinders the development of empathy?interjecting personal experiencesA nurse has been waiting for over an hour for the ancillary department of laboratory to draw blood on a non-critical client with bipolar disorder in the ED. Which response is an example of assertive communication from the nurse to the laboratory personnel?"When you are late to draw blood the family gets upset, and I don't like having to repeat that you are on your way."A psychiatric-mental health nurse is engaged in communication with a client. Which nonverbal behavior by the nurse would convey a positive message? Select all that apply.Nurse leans slightly forward in the chair. Nurse sits at the same eye level as the client.During the next meeting during the working phase of the relationship the client brings the nurse homemade chocolate chip cookies and a box of chocolates. Which response should the nurse make to the client about these gifts?"Thank you but I will not accept these gifts because they extend over our discussed boundaries."The client tells the nurse, "My mom is coming in to see me today," while sighing and looking out the window. The nurse states, "You don't seem very excited about the visit, is everything OK?" The client affirms. Using therapeutic communication, how should the nurse respond?"I'm concerned that you are not exicited about your mother's visit, We can talk if you want."The nurse is meeting with a client experiencing a mood disorder. Which client statement indicates that the nurse-client relationship has been established?"I feel worthless and have no real use in life."The nurse and client are discussing discharge plans. Which statement should the nurse make that demonstrates empathy for the client's fear of returning to a group home environment? You Selected:"It can be scary to leave a place that you trust and feel supported."The nurse has been providing regular care to a client diagnosed with an anxiety-related disorder for the past 2 weeks. Which statement made by the nurse suggests a possible professional boundary issue?"I am going to rearrange my schelude today so we can spend more time talking."While interviewing a client, the nurse imagines what it would be like to be in the client's situation and how it would feel. What is the nurse demonstrating?empathyA nurse and client are engaged in a therapeutic relationship. The nurse explains the boundaries of the relationship and clarifies expectations. The nurse and client are in which phase of the nurse-client relationship?orientationA psychiatric-mental health client tells the nurse, "The doctor hates me. The doctor promised to come check on me after dinner yesterday but never came." What is the nurse's most therapeutic response?"I don't know why the doctor didn't check on you yesterday, but I think it's unlikely that the doctor hates you."During an admission assessment, the nurse asks a client the meaning of the proverb, "People in glass houses should not throw stones." Which clinical feature is the nurse assessing?abstract reasoningA nurse awaits the arrival of a client who is being transferred from a nursing home. The client has a history of schizophrenia and has been behaving bizarrely. The nurse begins preparing the plan of care by outlining expected outcomes. The nurse's actions are which of the followingInconsistent with the nursing process, because assessment always comes firstA client's frequent night awakenings, early morning rising, and daytime drowsiness have prompted the nurse to add a diagnosis of "disturbed sleep pattern" to the client's plan of care. What information should immediately follow this diagnosis?The evidence supporting the diagnosisA client's nursing diagnosis of "risk for self-directed violence" has been identified because of her recent history of cutting and self-mutilation. Which of the following expected outcomes is most appropriate for this client's plan of care during inpatient treatment?"the client will refrain from cutting or self-mutilation"In planning the care of a client who has been admitted to the hospital after a suicide attempt, an expected outcome should relate directly to what?the client's refraining from suicide attemptsA mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what?incongruentA delusion represents a problem in which of the following areas?thinkingA nurse is completing a mental health assessment. When the nurse asks a client to interpret a proverb, the nurse is assessingabstract reasoningA delusion represents a problem in which area?thinkingA client is showing no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which term when documenting the client's affect?flat affectThe nurse asks the client, "What is similar about a cow and a horse?" and "What do a bus and an airplane have in common?" These questions would best assess which area?intellectual functionThe nurse asks the client, "What is similar about a cow and a horse?" and "What do a bus and an airplane have in common?" These questions would best assess which area?Emphasize the importance of truthful information using a nonjudgmental approach.A client is admitted to the psychiatric unit and states, "I am president of the largest corporation in the world. Everyone comes to me for advice." The nurse knows the client is exhibiting what?delusionA nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to completing the assessment. What is the most effective way for the nurse to proceed?complete the assessment in several short interactionsDuring the assessment of a client who has a pattern of eating-disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment?self-conceptWhat factor is most important in the psychosocial assessment of the mental health client in order to formulate a plan of care?chronological age and developmental levelA client with a history of schizophrenia states "I am the ruler of a magical land." When the nurse replies by stating who and where the client is, which interview behavior is the nurse using?presenting realityA nurse is initiating a new psychotropic medication for a client and is concerned about weight gain. What is an important baseline for the nurse to measure?body mass indexA client states to the nurse "I am so excited about my family coming to visit" and is smiling and laughing. How will the nurse document the client's mood?euphoricA client states, "I don't want to eat anything because I am afraid that my food is poisoned." Which intervention is best for the nurse to perform to encourage the client to eat?encourage the client to help with meal preparationA client taking lithium comes to the hospital for a 2-week follow-up. The client complains of a hand tremor that keeps from holding a coffee cup and states that the client feels confused, has stomach aches, and trips occasionally. Which would be the most therapeutic intervention of the psychiatric nurse?Call the client's psychiatrist because her symptoms are indicative of moderate toxicityThe most common therapy for seasonal affective disorder includes which of the following?phototherapyPrior to undergoing ECT, brief general anesthesia is given to prevent which of the following?severe muscle contractionsWhich correctly describes the primary effect of a selective serotonin reuptake inhibitor (SSRI) antidepressant drug?its ability to block the reuptake of serotoninIn the process of electroconvulsive therapy, what is electricity used to induce?a seizureHarry has noticed that in the fall and winter months he has a loss of energy, difficulty sleeping, and sadness. After seeking treatment, Harry is diagnosed with seasonal affective disorder. Which of the following treatments is effective for this conditionphototherapyWhich is the most commonly seen adverse side effect of typical antipsychotics?extrapyramidal symptoms and tardive dyskinesiaWhich reason do clients cite most frequently as the cause for self-discontinuation of medication?intolerable side effectsA client has been discharged from the hospital with a prescription for lorazepam. Which instruction should the nurse provide to this client?"Make sure that you don't drink any alcohol when you're taking this medication."Dietary modifications are most likely necessary when a client is being treated with which antidepressant?Monoamine oxidase inhibitors (MAOIs)A client is undergoing ECT. The nurse would be correct to inform the client of which aspect prior to the ECT?NPO will be employed 8 hours prior to the procedure.Which electrode placement during electroconvulsive therapy (ECT) is associated with the best outcomes?Bilateral electrode placement on the client's temporal areasA client is receiving clozapine. For which life-threatening disorder should the nurse be alert when assessing this client?agranulocytosisA client is being seen in the mental health clinic. The client has been on haloperidol for 8 months and is now exhibiting tongue protrusion, lip smacking, and rapid eye blinking. A nurse would document this chronic syndrome astardive dyskinesiaA nurse is leading a medication education group for clients with depression. A client states he has read that herbal treatments are just as effective as prescription medications. The best response is"we need to look at the research very closely to see how reliable the studies are"A psychiatric-mental health nurse is assessing a patient with bipolar disorder who is prescribed lithium. The nurse is evaluating the patient for compliance with therapy. The nurse woud be especially alert for complaints of which effect as most likely contributing to noncompliance? Select all that apply.Poor ability to concentrate Memory problemsDuring the stabilization phase of drug therapy for a client who is hospitalized with a psychiatric disorder, which action would be most appropriate?Assessing the client for target symptoms and side effectsA client is receiving risperidone as part of the treatment plan for schizophrenia. Assessment reveals breast enlargement and evidence of galactorrhea. The nurse interprets this effect as due to which occurrence?increased prolactin levelsA client who is taking lithium is scheduled to come to the community mental health center to have a blood level obtained. The client takes the last dose of lithium each day at 10 p.m. The nurse tells the client to hold the morning dose. At which time would the nurse tell the client to come to the center to have the specimen drawn?10amThe therapeutic range of serum lithium includes which levels?0.8 to 1.2From the standpoint of cognitive therapy, the term cognition refers to what?how clients think about themselves and their worldA nurse is reading a journal article about cognitive behavior therapy and cognitive processes involved in the development of common mental disorders such as depression. The nurse demonstrates understanding of the information by identifying which area as being included in the cognitive triad? Select all that apply.oneself world futureWhen clients are asked to consider the points of view of significant others in their lives, the nurse is asking which type of question?relationshipThe education provided to a client receiving cognitive behavioral therapy provides the client with information on the nature and course of the disorder and ...empowers clients to engage in a collaborative approach to their careAn "all or nothing at all" thought process is an example of which theme associated with irrational beliefs?An "all or nothing at all" thought process is an example of which theme associated with irrational beliefs?absolue thinkingWhich of the following reinforce the client's successes and strengths?complimentsRational beliefs accept that human beings are fallible and reject absolutes such as what? Select all that apply.never and alwaysA nurse working in a psychiatric facility identifies the goal of cognitive therapy (CT) to be what?restrictive how a person perceives eventsA therapist meeting with a client for the first time plans to use a type of therapy that focuses more on solutions than problems and that asks the client to explore his or her life. This type of therapy is referred to as ...solution-focused brief therapyAn instructor is teaching a class about the use of cognitive therapies in psychiatric nursing. Which statement made by a student identifies a need for further instruction?"lengths of stay for clients in inpatient settings are becoming larger each year"A client is using cognitive therapy as an adjunct treatment for bipolar disorder. Which would be an overall goal for this client related to the use of cognitive therapy for this condition?The client will engage in self-care independent of professional assistance.Considering that cognitive behavioral therapy (CBT) requires a clear understanding of one's own belief system, which client is not a candidate for effective CBT?The client diagnosed with schizophrenia 2 years ago.A psychiataric-mental health nurse is reinforcing the interventions used with a patient receiving solution-focused behavior therapy. Which question would be most appropriate to use as a relationship-focused question?"How are your children affected by your anger issues?"Which statement made by a client receiving cognitive behavioral therapy (CBT) demonstrates a basic assumption made by the psychiatric health care staff that influences the care provided?"I know I can do this; I can control my temper."A psychiatric-mental health nurse is interviewing a client who has come to the community mental health center for an evaluation of anger issues. Which client statement would the nurse interpret as an irrational belief?"Nobody understands the enormous stress I'm under, so what's the use."A psychiatric-mental health nurse is working with a client who is receiving rational emotive behavior therapy. While reviewing the client's history, the nurse identifies statements that reflect common themes associated with irrational beliefs. Which theme would the nurse most identify in these beliefs?Absolute thinkingA psychiatric- mental health advanced practice nurse is conducting rational emotive behavior therapy (REBT) with a client. When explaining the concept of consequences, which information would the nurse most likely include about dysfunctional consequences?they are the result of irrational beliefsA psychiatric-mental health nurse is assessing a client and evaluating a client's beliefs. The nurse determines that the client's beliefs are rational because the belief:reflects flexibilityA psychiatric-mental health nurse is working with a client. Which statement made by the client involved in solution-focused behavior therapy demonstrates effective use of a scaling question?"Now that I understand what triggers my fear of flying, it feels more like a 7 than a 5."Which technique reinforces the client's successes and the strengths needed to achieve those successes?giving complimentsA client who has been admitted for an appendectomy states, "I'm really afraid of the surgery because my mother died when she was admitted for an emergency surgery." When preparing to work with the client concerning this anxiety about the surgery, the nurse recognizes what?The client is expressing fear about the surgery. The client's fear is the body's physiologic and emotional response to a known danger.Which of the following disorders involves the emergence of varying personalities in a person that is associated with stress and conflict?dissociative identity disorderA client is learning to cope with anxiety and stress. The expected outcome is that the client will...changes reactions to stressorsIn the stress response, what is consistent with activation of the sympathetic nervous system?increased blood sugarA psychiatric-mental health nurse is reading a journal article about stress and the emotional responses to it. The nurse demonstrates understanding of the topic by identifying hope, compassion, empathy, and sympathy as being categorized as which type of emotion?borderlineAdaptation is a person's capacity to survive and flourish. Adaptation affects which areas? Select all that apply.Health Social functioning Psychological well-being CopingThe nurse is caring for a 51-year-old male who has just been diagnosed with stage IV colon cancer. The client now has an increased blood pressure and heart rate. His respiratory rate has increased. The nurse spends time talking with this client and notes that his vital signs are now back in the normal range. What would the nurse note has happened?the client is adapting to noxious stressorsA client being evaluated in the emergency room can not speak logically or follow directions. The client's family states she has been under a great deal of stress for about six months. Which of the following stages of Selye's stress adaptation stages is the client experiencing?exhaustionA 42-year-old client was recently diagnosed with hypertension. Which of the following occurrences would be a positive reaction to the acute stress of this new diagnosis?decreasing dietary sodium and fat intakeA client who has been awaiting the results of a bone marrow biopsy for several days is experiencing stress as a result of uncertainty and the possibility that abnormal cell growth may be detected. A physical examination and blood work would most likely yield which of the following results?Increased blood pressure and heart rate; increased antidiuretic hormone (ADH)A client tells the nurse that he or she has a Type A personality. The nurse can anticipate that the client will be ...competitiveA client can protect himself from the negative effects of stress with which of the following?social and emotional resourcesThe efforts one takes to manage situations that have been appraised as being potentially harmful or stressful refers to ...copingWhich statement about posttraumatic stress disorder (PTSD) is accurate?Estimates are that up to 60% of people at risk develop PTSD.A nurse is talking to a provider, who quietly and numbly tells the nurse about arriving at the scene of an automobile-pedestrian accident 3 days ago. The provider performed CPR on a victim, but it was unsuccessful. Which statement by the nurse would be most appropriate?"Tell me what you saw"Which intervention would be most effective for friends and family members to implement in order to boost the self-esteem of a person who has just experienced trauma or abuse?To help them to refocus their view of themselves from being victims to being survivorsThe psychiatric-mental health nurse is conducting an assessment of a client who has been under a large amount of interpersonal stress. In order to best assess the client's psychological domain, the nurse should:use a broad introduction, such as "let's talk about what you're feeling today"The nurse is conducting a mental health assessment of a client who has been experiencing low mood, anxiety and loss of pleasure for the past month. The client tells the nurse he comes from a "really big family." Despite this, the client tells the nurse he continues to feel alone. Select the nurse's best response." You can have lots of people in your social network and still feel isolated."Which of the following would not be expected to occur during the sympathetic response (or the fight-or-flight reaction) to a stressor?blood clotting ability decreasesA nurse is interviewing several clients who survived a school shooting ten years ago when they were in high school. Which clients should the nurse identify as having achieved adaptation following this event? Select all that apply.Nurse manager for the local hospital. Married, mother of three, who is a stay at home mother. Father of two who works in a tire store and has a second job as a mechanic.Which term is used to describe an activity used to release anger?catharsisThe nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following?client's safetyAccording to Johnson's systematic review of the literature about violence on inpatient psychiatric units, what is a predictor of violence?suspiciousnessWhich is one of the most common nursing diagnoses for clients experiencing intense anger and aggression?risk for self-directed violenceThe nurse is orienting a new staff member in an inpatient mental health unit when a client begins to act in a violent manner. The nurse should explain to the new staff member that some clients use violence and aggression to ...have their needs metA married client expresses to the nurse that the client's spouse's frequent nagging angers the client. The nurse role plays assertive communication techniques with the client. Which indicates that the client understands how to use assertive techniques effectively?"I feel unappreciated when you criticize me"The client is being assessed for anger attacks. Which psychiatric disorder makes a person mostsusceptible to anger attacks that do not result in physical aggression?depressionThe nurse is teaching a client to recognize early signs of anger and aggression. The nurse explores ways that the client can recognize what?restlessness and irritabilityIn the psychiatric setting, what is the most effective intervention in preventing the hostile client's behavior from escalating to physical aggression?engaging the hostile person in dialogueA nurse has determined that a client requires restraint. Based on guidelines, the nurse contacts the physician who must examine the client within which time frame?1 hourA nurse is conducting a class for a local community group about how to deal with anger in constructive ways. When discussing the benefits of managing anger constructively, which of the following points should the nurse include? Select all that applyAn improvement in mood Improved overall health Improved blood pressure controlA new nurse asks the nurse manager about the best intervention to use when trying to de-escalate a potentially violent client. Which response would be most appropriate?"What works best is what fits the client and the situation."Which behavior is considered inconsistent with the clinical picture of a client who is becoming increasingly aggressive?sobbing inconsolablyA psychiatric-mental health nurse is reviewing information about biologic theories associated with aggression. The nurse identifies which structure as being primarily involved?cerebral cortexA group of psychiatric nurses working in a community mental health center are participating in a training program for preventing and managing aggressive behavior offered regularly by the center. Which statement by the nurses indicates that the program was successful in achieving its outcome?"We have the most up-to-date information on the best ways to handle this problem."The nurse states "I know this must be frightening for you" to a client who is angry and has a potential for violence. Which communication technique is the nurse utilizing with this statement?validationA client is attending anger management class and wants to know how the class will help. What is the nurse's best response?"it will help you to learn how to control the arousal of anger"The nurses on a mental health unit are reviewing aspects of the unit environment in a staff meeting. Which factor would be predictive of a client becoming aggressive or violent?strict hierarchy of authorityThe nurse is working with a client who is glaring at the other clients and has begun to pace in the dayroom. In determining an intervention to prevent escalation to violence, which would the nurse choose? Select all that the client personal space approaching the client calmly overlooking the client's behaviorA nurse's response to aggressive behavior on the unit is influenced by which characteristic of the nurse?Self-awareness of reactions to aggression by othersTo care for an acutely suicidal client, which is the most effective initial mode of treatment?inpatient careA client who lost a child as a result of an automobile accident by an impaired driver is seen by the nurse in an outpatient mental health clinic. He is exhibiting signs of depression in the context of complicated grief. During the session, the nurse should recognize which of the following as a priority?assessing the client for suicidal ideationsThe tendency for suicide to have a "contagious" effect is most likely to occur among what age group?high school studentsThe nurse is assessing a client for warning signs of suicide. Which would be a concern?The nurse is assessing a client for warning signs of suicide. Which would be a concern?the client has engaged in risky behaviors and tends to be impulsiveFollowing the failure of a woman's recent in vitro fertilization (IVF), the nurse recognizes that she may be at risk of depression. Which intervention is considered a primary suicide prevention measure?Establishing a support system for the woman and teaching her some coping measuresSeveral questions can be used to assess a suicidal person's intent to die, the severity of the suicidal ideation, and the degree of planning. Which question may be used to elicit information regarding the severity of suicidal ideation?Can you dismiss thoughts of killing yourself, or do they tend to return?Trying to kill oneself and surviving the ordeal is identified as what?suicide attemptA nurse is preparing a client for discharge. As part of the discharge process, the nurse provides education to the client regarding safety from self-harm. Which intervention should the nurse employ?Include family members to provide a better understanding of symptoms of the illnessThe nurse is interviewing a client with a diagnosis of depression and the client states, "Honestly, I know my family would be a lot better off if I wasn't around to be a burden on them. That's just between you and me, though, okay?" What is the nurse's best response?"I'm obliged to share what we talk about with the other people on your care team."The policies and procedures at a community psychiatric-mental health center include an emphasis on case finding. How can a nurse at the center best perform case finding?Assessing all clients carefully to identify those at risk for suicideThe nurse is caring for an inpatient who has a diagnosis of depression and who describes pervasive thoughts of suicide this morning. In order to redirect this patient's current mindset, the nurse should:provide the patient with meaningful and appropriate distraction.The nurse is caring for an inpatient who has a diagnosis of depression and who describes pervasive thoughts of suicide this morning. In order to redirect this patient's current mindset, the nurse should:provide the patient with meaningful and appropriate distraction.A client with a diagnosis of schizophrenia has been admitted to the psychiatric mental health unit following a suicide attempt. Shortly after admission, the client has agreed to a commitment to treatment statement (CTS). What effect will the CTS have on the client's inpatient care?The client explicitly agrees to participate in all aspects of treatmentA client has been successfully treated on the psychiatric mental health unit following a suicide attempt. In preparation for discharge, the nurse should prioritize what action?ensuring a plan is in place for the client's community-based careA client has admitted to the nurse that the client is "tempted to end it all." How can the nurse prevent a future malpractice lawsuit if the client makes a suicide attempt?promptly act on, and document, the client's statementThe nurse caring for a client who is high risk for suicide on a psychiatric inpatient unit can help the client re-establish a sense of control by including what in the client's care?asking the client about diet preferences for mealsThe nurse has been caring for a 77-year-old client who was admitted to the psychiatric unit for depression and imminent suicide risk. Despite varying levels of intervention, the client continues to voice suicidal ideation with a lethal plan. Which intervention should the care team employ?use ECTThe nurse is seeing a client for counselling in a mental health clinic. The nurse notes the client has new superficial cuts to the inside of the upper forearm. Which is the best way for the nurse to discuss this observation with the client?"I notice some cuts on your arm. Am I correct to think that things have been difficult?"A nurse is reviewing the medical record of a young client to determine the client's risk for suicide. Which factor would alert the nurse to an increased risk for this client?experiencing unemployment that has lasted a yearA 35-year-old client with bipolar disorder has a history of discontinuing medication when feeling well and then becoming manic again. During the client's last episode of mania, the client lost several thousand dollars in risky investments. Which intervention will be mosthelpful in achieving medication adherence?During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse.The nurse is seeing a 26-year-old client and the client's family. The client's family describes the client as being "very, very different." The family describes a history of periods of unpredictable behavior and disregard for consequences occurring a few times each year. The client has recently been diagnosed with bipolar I disorder, a condition that is characterized by what?an elevated mood that lasts for at least 1 weekWhich sleep pattern is suggestive of a manic episode?A client stays awake for several days and nights before "crashing" and sleeping for a long period.In a report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. The best response by the nurse would be ..."Let's go to the conference room and talk for a while"Administration of lithium affects which of the following electrolytes?sodiumA client who has liver damage is receiving lithium for treatment of bipolar disorder. The nurse understands that which of the following may occur when the client is receiving lithium?increased plasma concentrationWhich behavior is the priority concern as the nurse begins a care plan for a client in the manic phase of bipolar disorder?hyperactivity, dismissing meals, and sleep disturbanceA client in the clinic appears to have elevated self-esteem, is more talkative than usual, and is easily distracted. This client is exhibiting symptoms of what?grandiosityA client who has just been prescribed lithium for bipolar disorder is being given education from the nurse about this medication. Which is important for the nurse to include in teaching?the higher the sodium level, the lower the lithium level will beA client who has been taking lithium for bipolar disorder is admitted to the hospital with the following symptoms: dry mouth, nausea and vomiting, blurred vision, dizziness, and muscle twitching. What should the nurse suspect?moderate lithium toxicityA client taking lithium for bipolar disorder is having mild diarrhea. The nurse informs the client that this is an example of what?side effectA client with bipolar disorder has been ordered a medication that is classified as an anticonvulsant. Which drug does the nurse know falls within this class of medications?carbamazepineA client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?other clients need to be protected from the intrusive behaviorA client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?Which is a possible explanation for the increased risk of suicide in persons who have had a relative who committed suicide?The relative's suicide offers a sense of "permission" or acceptance of suicide as a method of escaping a difficult situationA visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of the client's favorite soda. Which action should the nurse take at his time?pour the soda into a plastic cupA nurse is caring for a client diagnosed with bipolar disorder. The client is experiencing a manic episode. The nurse would be especially alert for signs indicating what?self-injuryA patient with bipolar disorder is prescribed divalproex. Before initiating this therapy, which laboratory test would be most important for the nurse to obtain?liver function testsThe nurse is reviewing the history of a client diagnosed with bipolar I disorder. The history reveals that the client, in between manic episodes, consistently uses self-negating statements when describing the self, expresses feelings of being ashamed, and describes self as being unable to deal with events. The client also demonstrates little to any eye contact during interactions. The nurse interprets this information as reflecting a problem in which area?self-esteemA nurse is reviewing the medical record of a client prescribed lithium carbonate. The nurse would be alert for possible increases in serum lithium concentrations based on the client's use of which substance? Select all that apply.Furosemide Alcohol Fluoxetine IbuprofenThe genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should ...assess for depression in the client's family historyWhich disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode?dysthymic disorderWhich antidepressant medication is classified as a selective serotonin reuptake inhibitor (SSRI)?FluoxetineA nurse is caring for a client receiving a tricyclic antidepressant and is monitoring for anticholinergic side effects. Anticholinergic effects include which of the following?blurred visionA client with major depression is admitted to the health facility and expresses feelings of worthlessness and abandonment by significant others. Which replies by the nurse would convey empathy?"it sounds like this is a really difficult time for you"The nurse working on a mental health unit is teaching a nursing student. The student asks the nurse about what constitutes a diagnosis for major depressive disorder. What is the nurse's best response?"The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present."A client is admitted for major depression. The client has stated that nothing seems to bring the client pleasure anymore. What should the nurse expect to find during assessment?anhedonia, feelings of worthlessness, and difficulty focusingA client who is depressed begins to cry and states, "I'm just really sick of feeling this way. Nothing ever seems to go right in my life." Which would be the most appropriate response by the nurse?A client who has been discharged home on citalopram calls the nurse reporting that the medication causes the client to feel too drowsy. The nurse should make which suggestion?take the medication at nightThe client has been diagnosed with severe depression. During the assessment of the client, the nurse is aware of which primary consideration with clients taking antidepressants?suicideElectroconvulsive therapy would be contraindicated for a client with:increased ICPBefore a client became depressed, the client was an active, involved parent with three children, often attending their school functions and serving as a volunteer. The client is hospitalized for a major depressive episode and now reveals that the client feels like an unnecessary burden on the client's family. Which nursing diagnosis is most appropriate?situational low self-esteemA client with major depression is scheduled to receive electroconvulsive therapy. The nurse understands that this treatment is typically used in which situation?the client is experiencing catatoniaWhen completing a baseline assessment of a client with depression, which diagnostic tests would the nurse anticipate?thyroid function testsWhich is a true statement regarding depressive disorders?The neurotransmitters norepinephrine, dopamine, and serotonin have been implicated.A client with major depression is prescribed paroxetine. The nurse develops an education plan for the client based on the understanding that this drug belongs to which class of drugs?SSRIsA client with major depression and a suicide attempt is admitted to the inpatient facility. The client is started on antidepressant therapy. The next day, the client demonstrates significantly higher energy and says, "I'll feel much better." The nurse would interpret this behavior as suggesting what?possible decision to complete a suicide attemptThe nurse is planning the inpatient care of a client who has been admitted with major depression. The client's plan of care includes regular exercise, but the client is reluctant to participate due to a lack of energy and motivation. What is the nurse's best action?Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effortWhich outcome would be appropriate to determine an early favorable response to antidepressant medication?The client will establish a balance of rest, sleep, and activity.A psychiatric-mental health nurse is assessing a client who is suspected of experiencing depression. During the interview, the client says, "I just don't care any more. I used to enjoy doing all sorts of things outdoors, but now, I don't. Nothing seems to make me happy." The nurse interprets this statement as:anhedoniaA client who experiences panic anxiety around dogs is sitting in a room with a dog and the client's nurse therapist. The nurse therapist is using which behavioral intervention for this type of anxiety?systematic desensitizationA patient with anxiety disorder has excessive anxiety and worries about multiple life circumstances. For how long would this patient experience these feelings before the anxiety disorder would be considered chronic and generalized?6 monthsA nurse is giving a presentation on mental health promotion to college students. One student asks the nurse to explain the difference between normal anxiety and an anxiety disorder. Which response is best?"People with anxiety disorders generally find that the anxiety interferes with daily activities."A client with generalized anxiety disorder states that the client is worried about the client's job. The client never feels like the client has control over the client's responsibilities, even though the client puts in extra hours. The client adds that the client is afraid the client will be fired. Which response by the nurse is most therapeutic?"Has something changed at work that is causing you to worry?"Which of the following is inconsistent with panic-level anxiety?this level of anxiety can be sustained indefinitelyA client is experiencing a panic attack. Which term describes sensing that things are not real?derealizationWhen a parent observes the parent's young child heading toward a busy road the parent becomes stressed, feeling the parent's heart pounding, breathing heavily, and hands becoming wet with perspiration. Which physiological system is activated with the parent's "fight or flight" reaction to this danger?sympathetic nervous systemA client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor?coping mechanismA young parent tells the nurse, "I can't stop smoking. That is what I do to make myself feel better." What is the term used to describe this behavior?coping mechanismA client is currently experiencing a panic attack. Which is the most appropriate response by the nurse?"you are safe. take a deep breath"A client states, "I will just die if I don't get this job." The nurse then asks the client, "What will be the worst that will happen if you don't get the job?" Why does the nurse ask this question?to help the client appraise their situation more realisticallyThe nurse is teaching about postoperative wound care. As the wound is uncovered, the client begins mumbling, breathing rapidly, and trying to get out of bed, and the client does not respond when the nurse calls the client's name. Which should be the nurse's first action?replace the dressing on the woundA client asks the nurse, "Why do I have to go to counseling? Why can't I just take medications?" What would be the most appropriate response by the nurse?"Medications combined with therapy help you change how well you function."An anxiolytic agent, lorazepam, has been prescribed for the client. Which statement by the client would indicate to the nurse that client education about this medication has been effective?"this medication will relax me, so I can focus on problem solving"The nurse is caring for clients in the outpatient unit. Which would be key points for the nurse to remember when working with clients who are suffering from anxiety disorders?Remember to practice techniques to manage stress and anxiety in the nurse's own life.Which medication classification has most commonly been used to treat social phobia?SSRIsA nursing instructor is describing the care of a client with acute anxiety to a class of nursing students. The instructor determines that more education is necessary when the students identify which intervention as appropriate?providing the client with a comforting touchA client is currently experiencing panic. Which action would be most appropriate for the nurse to do?allow the client to paceA nurse is seeing a client prior to discharge after being admitted to hospital for suicidal ideation. As the nurse begins the discharge process, the client closes the eyes and begins rapid, shallow breathing. The client also begins to shake and perspire profusely. Which actions should the nurse take? Select all that apply.Talk to the client in a comforting manner. Take the client to a quiet space. Reassure the client of being safe.A nurse is seeing a client who is having severe to panic level anxiety after a physical assault months previously. The client tells the nurse, "When the panic starts I feel like I am watching myself through a window." The nurse can most accurately describe this experience as:depersonalizationOne major difference between posttraumatic stress disorder (PTSD) and the other anxiety disorders is that ...symptoms being after exposure to a traumatic stressorPosttraumatic stress disorder (PTSD) has been diagnosed in a sexually assaulted female client. Which of the following manifestations is the most consistent with PTSD?flashbacksA client who has experienced intimate partner violence (IPV) for many years has just been diagnosed with post-traumatic stress disorder (PTSD). The nurse realizes that this will increase the client's risk for which of the following?suicideThree years after the nurse's father died in an intensive care unit, the nurse was reviewing a client's chart. The nurse looked at the client, who had the same diagnosis and similar features to the nurse's father. The nurse felt a sense of panic but quickly realized that the client in the bed was not their father. Which of these manifestations of PTSD did this nurse experience?a flashbackA client has been referred for care because the client's primary care provider suspects that the client has posttraumatic stress disorder (PTSD) following a motor vehicle accident. When working with this client, the psychiatric-mental health nurse should begin by:establishing therapeutic rapport with the clientWhen lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what?failure to integrate identity, memory and consciousnessThe nurse is working with two children who have been apprehended from a neglectful and abusive home. Initial assessments reveal that one child is much more traumatized than the other, despite similarities in their circumstances. The nurse should consider what possible explanation for their differing responses?the children have differing levels of resilienceThe psychiatric-mental health nurse is providing care for a child who has been diagnosed with disinhibited social engagement disorder. What intervention best addresses the characteristics of this disorder?teaching the child how to interact appropriately with strangersWhat assessment finding would suggest to the nurse that the client with posttraumatic stress disorder (PTSD) is experiencing dissociation?the client is often "staring into space" and has no idea how much time has passedThe nurse is working with a client who is suspected of having posttraumatic stress disorder after witnessing a violent crime. What statement by the client's spouse would suggest that the client is experiencing hyperarousal?A client who is being treated for posttraumatic stress disorder tells the nurse, "Sometimes it's like I can't feel anything—not happiness, not sadness, not fear. Nothing." How should the nurse best interpret the client's statement?the client's emotional numbing is a protective mechanismThe psychiatric mental health nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) after the death of the client's child from a medical error. What assessment finding would most warrant interventions aimed at addressing the client's dissociation?the client reports large gaps in memory of the traumatic eventA client with posttraumatic stress disorder (PTSD) has been prescribed lorazepam 1 mg SL q6h PRN. What assessment finding indicates that treatment is having the desired effect?reduced anxietyA client with a history of intimate partner violence has been diagnosed with posttraumatic stress disorder. The client is wholly unwilling to discuss any aspects of personal history or current mental status with the nurse. What is the nurse's best initial action?make efforts to demonstrate empathy to the clientThe nurse is performing a physical health assessment of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What aspect of this assessment should the nurse prioritize?sleep assessmentA client with post-traumatic stress disorder (PTSD) tells the nurse, "Every morning I wake up with a vicious hangover and swear I'll never drink like that again. Yet, every night I some how end up at the bar." The nurse should consider the possibility of what nursing diagnosis?ineffective impulse controlA nurse's colleague expresses sympathy for a client who is traumatized following a terrorist attack 1 week earlier. The colleague states, "I'm certain that the client has posttraumatic stress disorder (PTSD)." What is the nurse's best response?"Acute stress disorder is a possibility, which might develop into PTSD."A police officer was diagnosed with posttraumatic stress disorder after attending to a violent crime scene. What aspect of the client's current health status would most likely warrant inpatient treatment?the client alluded to "ending this misery" in a conversation with a colleagueThe nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) several months ago. During a comprehensive follow-up assessment, what areas should the nurse assess? Select all that apply.The client's use of alcohol or other drugs Characteristics of the client's sleep The effect of the client's PTSD on the familyA nurse is reviewing the medical records of several clients who have come to the community health center. The nurse would most likely identify a client experiencing which event as being at risk for developing posttraumatic stress disorder (PTSD)? Select all that apply.Being a survivor of a tsunami that resulted in thousands of deaths Being a marine in a combat situation where the entire platoon was wiped out, except for one person Being hidden in a closet and hearing the entire family murdered by someone who broke into the homeWhich would not increase the likelihood that an older adult will incur physical abuse?the older adult who is independent with ADLsWhich of the following nursing interventions would be the most appropriate to prevent a client from becoming violent?helping the client identify and express feelings of anxiety and angerWhich type of elder abuse involves harm of self-worth?emotionalWhich of the following are biologic indicators of posttraumatic stress disorder (PTSD)?flashbacksApproximately what percentage of women rape victims are raped by someone they know?65%A nurse is giving a talk about child abuse to a local community group. When discussing risk factors for child abusers, which would the nurse identify as the most likely profile of the perpetrator of fatal child abuse?unemployed young woman who dropped out of high schoolThe nurse is collecting assessment data on a client who is suspected to be a victim of violence. Which assessment data would support the suspicion that the client is a victim of abuse? Select all that apply.The client has few friends. There is a large amount of alcohol use in the home. The client reports that the client's father was abusive during childhood.The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital for a fractured femur. Which data obtained during the assessment would raise the nurse's suspicion that the child has suffered physical abuse?The injury occurred several days before the parents sought treatmentA client has just presented at the emergency department after being raped. What initial action by the nurse would be most appropriate?provide emotional supportA young client telephones the emergency department and loudly tells the nurse, "I've been raped! Please help me!" Which is the priority for the nurse to determine?If the client was in a safe place, the client's condition, and if transportation is availableThe nurse is discussing expectations of raising a child with a pregnant teenager expecting her first baby. The father will not be a participant in the parenting. Which statement made by the expectant mother would be of greatest concern to the nurse?"My child will love me, unlike my parents ever did."The community health nurse meets with the family members of an older adult client. The nurse includes which in the plan of care as a preventive measure to guard against elder abuse?Provide the primary caregiver with additional resources to meet the client's needsThe nurse is assessing an older adult in the emergency department. The client has many bruises on the body in varying stages of healing. After documenting the bruising in the assessment, what should the nurse do next?Ask the client when and how the bruises occurredA nurse is aware of the high incidence of intimate partner violence (IPV) and actively seeks opportunities to screen women for IPV. Which female client represents the best opportunity for assessing for IPV?A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinicThe nurse can assess potential victims of domestic violence by asking which question?"has a past or current partner ever caused you to be afraid?"A nurse is assessing a client in a community clinic who reports feeling anxious lately because she is considering leaving her marriage. The client describes a long history of partner abuse associated with this relationship. How should the nurse respond to this client?"you have the right to be safe and respected"A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply.A 6-year-old is being seen for the 5th time for a urinary tract infection A baby with contrecoup injuries to the brain A 3-month-old with a fractured femurA nurse manager is working with the nursing staff of a busy community-based walk-in clinic that provides care to a large number of survivors of domestic violence. When helping the staff provide care, which information would be most important for the nurse manager to convey to the staff?Importance of measuring the clients' progress in small stepsWhich are forms of psychological abuse? Select all that apply.Insulting Humiliating isolating a person from familyApproximately what percentage of women are victims of intimate partner violence (IPV)?25%Which of the following is a primary risk factor for suicide?social isolationWhich is the greatest predictor of a future suicide attempt?previous attempt