Scheduling clinic appointments at shorter intervals will give the opportunity for more frequent assessment of symptoms and allow the nurse to use early intervention. Option A is wasteful of scarce resources. Option C: If the client does not admit to having a crisis or problem this referral would be useless.
Option D: This may or may not produce reliable information. Option D: Depot medication is a strategy to reduce noncompliance and is often preferable to daily oral medication. Options A and C do not directly relate to the noncompliance problem. My roommate moved out and the rent is too much for me to pay on my own.
To top it all off, my therapist is moving out of state. Subjective and objective data obtained by the nurse suggest the client is experiencing anxiety caused by multiple threats to security needs. Option A: Data are not present to suggest decisional conflict, ethical conflicts around treatment causing spiritual distress, or deficient knowledge. This client could profit from the structure and supervision provided by spending the day at the partial hospitalization program.
During the evening, at night, and on weekends his wife could assume responsibility for supervision. Option A: This client would need hospitalization. Option B: This client could be referred to home care.
Option C: This client could continue on the same plan. Best outcomes are achieved when clients have regular, frequent follow-up in the community. Options B and C provide too little follow-up. Option D provides a more intensive follow-up than may be required. Rationale: Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options.
If a client is homeless or fears homelessness, focusing on other treatment issues is impossible. Option B: Sufficient income for basic needs and medication is necessary. Option C: Adequate support is a requisite to community placement. Option D: This information has less bearing on the success of community treatment than the issues related to daily living arrangements.
Option E: Substance abuse undermines medication effectiveness and interferes with community adjustment. Rationale: Each of the correct answers is an example of appropriate nursing foci: communicating at a level understandable to the client, using holistic principles to guide care, and providing medication supervision.
Option C suggests a laissez faire attitude on the part of the nurse, when the nurse should provide thoughtful feedback and help clients test alternative solutions. Option E is a boundary violation. The aspect of nursing care this nurse must have an advanced practice nurse perform is. Prescriptive privileges are granted to masters-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level is permitted to perform mental health assessments, establish relationships, and provide individualized care planning.
He has been taking a selective serotonin reuptake inhibitor for 1 week without remission of symptoms. The priority nursing diagnosis is. Risk for suicide is the priority diagnosis when the client has both suicidal ideation and has developed a plan to carry out the suicidal intent. Imbalanced nutrition and chronic low self-esteem are viable nursing diagnoses, but these problems do not affect client safety as urgently as would a suicide attempt.
Ineffective protection would be of greater concern if the client were taking risperidone or an immune suppressant drug. The nurse must plan interventions directed toward meeting the client outcome: Client will refrain from gestures and attempts at killing self.
The nursing intervention most directly related to this outcome is. Option D is the only option related to client safety. Option A relates to nutrition. Option B relates to self-esteem.
Option C relates to medication therapy. The desired outcome is that client will sleep for a minimum of 5 hours nightly by October On November 1 review of sleep data for the 6 days of hospitalization shows the client sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The outcome can be evaluated as. Although the client is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore the outcome must be evaluated as never demonstrated.
The desired outcome is that the client will sleep for a minimum of 5 hours nightly by October On November 1 sleep data show the client sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. After the evaluation, the nurse should. Sleeping a total of 5 hours at night is still a reasonable outcome. Extending the time frame for attaining the outcome is appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap.
Option A is inappropriate. At the very least, the time in which the outcome is to be attained must be extended. Option B could be used when the outcome goal has been met and the problem resolved. Option C is inappropriate because no other nursing diagnosis relates to the problem. When documenting the baseline data obtained during the interview the nurse should include.
Both content and process of the interview should be documented. Option A provides a skewed picture of the client. Option B is subjectively worded. An objective description of client behavior would be preferable. Option D: Speculation is inappropriate. Assessment should include data obtained from both the primary and reliable secondary sources. The best action for the nurse would be to. The nurse should not impose outcomes on the client; however, the nurse has a responsibility to help the client evaluate what is in his or her best interests.
Exploring possible consequences is an acceptable approach. I constantly think negative thoughts about myself. I feel anxious and shaky all the time. Sometimes my mood is so low that I think I want to go to sleep and never wake up. The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to client safety. Client safety is always a priority concern. The nurse would also be expected to monitor and reinforce all client attempts to control anxiety, control depression, and develop self-esteem while giving priority attention to suicide self-restraint.
The outcome describes social involvement on the part of the client. Neither cooperation nor independence has been an issue. The client has already expressed a desire to interact with others. Nursing behaviors relating to implementation include considering available resources, performing care-giving interventions, finding alternatives when necessary, and coordinating care with other team members.
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation.
Option A is an example of PIE charting. Option B is an example of focus documentation. Option D is an example of narrative documentation. In this case the nurse should. When the client primary source is unable to provide information, secondary sources should be used, in this case the granddaughter. Later, more data may be obtained from other relatives or neighbors who are familiar with the client.
Option C: An experienced nurse would probably do no better. Option D is unnecessary. Option C: A catastrophic reaction refers to an angry, sometimes violent reaction by a client with dementia. Option D: The nurse is responding honestly rather than coping defensively.
The nurse should not try to pry information out of a client who is reluctant to give the information. Option A implies the client has been dishonest. Option B treats the client in a demeaning fashion. Option C is game playing. The client has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse.
Option A is not strictly true. Option B will not inspire the confidence of the client. Option D is confrontational. Option C: Direct questions might better identify treatment objectives. Option D: The mental status examination would be preferable.
The client also leans forward and frowns as she listens intently to the nurse. An appropriate question for the nurse to ask would be. Identifying any physical need the client may have at the onset of the interview and making accommodations are important considerations. Option A: The nurse is jumping to conclusions. Option C may not elicit a concrete answer.
Option D is a way of asking about the presence of auditory hallucinations, which is not appropriate because the nurse has observed that the client seems to be listening intently to her. When discussing coping strategies the nurse might ask what the client does when he or she becomes upset, what usually relieves stress, and to whom the client goes to talk about problems. It would seem out of place if introduced during exploration of the other topics. In doing this the nurse is engaged in.
Option A: Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Option B: Health teaching involves identifying health education needs and giving information about these needs. Option D: Psychobiological interventions involve medication administration and monitoring response to medications.
Interventions: Initiate suicide precautions. Allow client to retain personal belongings. Allow client to leave unit unsupervised. More than one answer may be correct. Rationale: All interventions are not supported by evidence. Evidence supports removing personal property that can be used to attempt self-harm. Evidence also supports restricting the client to the unit and closely supervising client activity while on the psychiatric unit. If the client leaves the unit, staff would accompany the client on a one-to-one basis.
The interventions are inappropriate because they do not provide a safe environment for the client. Option A: The interventions are feasible although misguided.
Option D: The interventions are within the capability of the nurse, but a nurse using good judgment would question them. The functions accomplished with this tool include more than one answer may be correct.
The data obtained also permit comparison for research purposes of client responses with those of groups of people with the same illness. This scale does not refer directly to nursing diagnoses, although data gathered may indirectly assist the nurse in formulating nursing diagnoses. The information that will be conveyed by the nursing diagnoses includes more than one answer may be correct. Rationale: Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.
Because the client is suspicious and fearful, reassuring him of his safety may be helpful, although he is unlikely to trust the nurse so early in the relationship. Option D suggests to the client that the nurse is not willing to try to understand his views. Option F may be perceived as a threat. The technique of exploring is useful because it helps the nurse examine meaning.
Option 2 directly asks for clarification. Option A focuses on client feelings. Options C and D fail to clarify the meaning of the word in question. The nurse can make the assessment that communication was not understood because of. Various personal, environmental, and social factors may be responsible for ineffective communication.
In this case, a personal factor is involved. The nurse used a highly technical explanation of his purpose for talking with the client. Data are not present in the scenario to support the choice of any other option.
We usually agree on everything. What assessment can the nurse make? Mixed messages involve the transmission of conflicting or incongruent messages by the speaker. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.
The nurse can correctly assume that. The data presented are insufficient to draw a conclusion. The nurse must continue to gather information. Option B offers false reassurance. This is a nontherapeutic technique that suggests to a client that his or her views and feelings are not being taken seriously.
Options A, C, and D use therapeutic techniques. He has been silent and sullen most of the session and has been staring at the floor for the last 10 minutes. Option B is undesirable because it may prompt relapse. Option D would not resolve the problem because risperidone also produces sedation. The anticonvulsants mentioned alter electrical conductivity in membranes, slowing the firing rate of brain neurons. This membrane-stabilizing effect probably accounts for the reduction in mood swings seen in bipolar clients.
Option C is the action of soporific benzodiazepines such as flurazepam Dalmane. Option D: Psychostimulation is produced by drugs such as methylphenidate Ritalin , which are used to treat attention deficit hyperactivity disorder. Rationale: These queries are neutral in tone and do not express bias for or against the use of herbal medicines.
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Varcarolis - Test Bank quantity. Previous Product. Category: Nursing. Perhaps you should ask the doctor to tell you more. For the physician to make a differential diagnosis with the least expensive test, the nurse should expect to prepare the client for a A. PET scan. ANS: A The CT scan could be expected to show the presence or absence of cortical atrophy, ventricular enlargement, and areas of infarct, information that would be helpful to the physician.
Cerebral arteriogram D. The question that best implements this assessment is A. ANS: A Dopamine is a neurotransmitter found in areas of the brain responsible for decision making and integrating thoughts and emotions. ANS: D Increased acetylcholine plays a role in learning and memory. The nurse can anticipate that a PET scan would be most likely to show dysfunction in the part of the brain called the A.
ANS: D The frontal lobe is responsible for intellectual functioning. ANS: A Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. ANS: A If the reuptake of a substance is inhibited, it accumulates in the synaptic gap and its concentration increases, permitting ease of transmission of impulses across the synaptic gap. ANS: A Medication that blocks dopamine is often seen to produce disturbances of movement such as akathisia because dopamine affects neurons involved in both thought processes and movement regulation.
The nurse would suspect the presence of a high concentration of brain A. On the basis of this finding, the nurse should assess the client for symptoms of electrical conduction problems A. ANS: A The brain is involved in mental activity, maintenance of homeostasis, and control of all physiological functions.
To prepare a care plan, the nurse must correctly hypothesize that the client will need teaching about a drug from the group called A. ANS: C Benzodiazepines provide anxiety relief.
Of the medications listed below, the nurse can expect to provide the client with teaching about A. The nurse can begin care planning based on the expectation that the psychiatrist is most likely to prescribe a medication classified as a n A.
ANS: B The symptoms describe a manic attack. This alerts the nurse to assess the client for A. ANS: D Muscarinic receptor blockade includes atropinelike side effects such as dry mouth, blurred vision, and constipation.
Chew sugarless gum B. Eat plenty of roughage C. Arise slowly from bed D. Report muscle stiffness ANS: D Phenothiazines block dopamine receptors in both the limbic system and basal ganglia. ANS: B The client is asked to protrude the tongue for several seconds to enable the nurse to assess for fine movements of the tongue, a possible indicator of tardive dyskinesia related to long-term phenothiazine therapy.
MAO inhibitor. ANS: D Fluphenazine, a first-generation antipsychotic, exerts muscarinic blockade, resulting in dry mouth, blurred vision, constipation, and urinary retention. Report sore throat and fever immediately. Avoid foods high in polyunsaturated fats. Practice unprotected sex. Use over-the-counter preparations for rashes. ANS: A Clozapine therapy may produce agranulocytosis; therefore signs of infection should be immediately reported to the physician. The nurse must check to ensure that a special diet has been ordered for each client receiving A.
ANS: A Depression is thought to be related to lowered availability of the neurotransmitter serotonin. The nurse planning care for the client must consider that atypical antipsychotics A. ANS: D Atypical antipsychotic drugs often exert their action on the limbic system rather than the basal ganglia. The nurse should A. ANS: B These laboratory values indicate the possibility of agranulocytosis, a serious side effect of clozapine therapy.
ANS: C Sympathetic mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. The client receiving lithium Lithobid B. The client receiving clozapine Clozaril C. The client receiving fluoxetine Prozac D. The client receiving venlafaxine Effexor ANS: A Lithium is known to alter electrical conductivity, producing cardiac dysrhythmias, tremor, convulsions, polyuria, edema, and other symptoms of fluid and electrolyte imbalance.
ANS: B Tacrine is an anticholinesterase drug that works by increasing the concentration of acetylcholine at the synapse. ANS: A H 1 receptor blockade results in weight gain, which is undesirable for an obese client. A solution the nurse should discuss with the physician is A. ANS: C Taking the medication at bedtime when the sedation would not be problematic may also reduce daytime sleepiness.
ANS: B The anticonvulsants mentioned alter electrical conductivity in membranes, slowing the firing rate of brain neurons. Add to cart. Seller Follow. NurseWilliams Member since 4 months 28 documents sold. Also available in bundle 2. Exam elaborations - Testbank-introduction-critical-care-nursing-7th-sole Exam elaborations - Maternal child nursing care 6th editiontestbank solutions. Exam elaborations - Gerontological nursing 9th edition eliopoulos test bank.
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