A patient is in a withdrawn catatonic state and exhibits waxy flexibility. During the initial phase of hospitalization for this patient, the nurse's first priority is to: Watch for edema and cyanosis of the extremities. Encourage the patient to discuss concerns that led to the catatonic state. Provide a warm, nurturing relationship, with therapeutic use of touch. Identify the predisposing factors in the illness. Circulation may be severely impaired in a patient with waxy flexibility who tends to remain motionless for hours unless moved. Answer 2 is not the first priority. "Touch" is not used in this stage, as in Answer 3. Answer 4 is incorrect because the patient is mute and also because intellectual discussion of predisposing factors ignores the feelings of the patient. Note the key words: "first priority." An elderly client who has dementia related to cerebral arteriosclerosis says to the nurse, "I'm going to the university to day to be their guest lecturer on aerodynamics." Which response by the nurse would be most therapeutic? Do you know that you are in the hospital now? Are you saying that you would like to be asked to give a lecture at the university? How about watching a movie on television instead? It's more important that you don't tire yourself out. The best of four poor choices here is an attempt to understand what the client means. The other choices are not helpful. Answers 3 and 4 switch the focus and ignore the client's statement; Answer 1 is too brusque an attempt to bring the client back to reality. Asking for clarification is a therapeutic communication technique. Which nursing approach would be best for a client with symptoms of severe depression? Allow the client time for quiet thought; remain silent. Ask the client to join the nurse and the other clients in the TV lounge. State that the nurse would like to go with the client for a short walk around the outside grounds, and assist the client with his or her coat. Give the client a choice of recreational activities. This will reduce the isolation and withdrawal while at the same time not putting the burden of decision making on the client. The client needs a structured routine that is simple. The client may not be able to handle close proximity to more than one person at this point, as in Answer 2. Answer 1 incorrectly allows the client to remain isolated; Answer 4 is incorrect because the client needs a structured routine until he or she can make decisions for himself or herself. Review theory on depression. Activity is a therapeutic intervention, on a 1:1 basis, and without requiring an answer or verbal interaction. When assessing clients who are exhibiting a depressed episode and those who are exhibiting a manic episode of bipolar mood disorders, which characteristic common to both episodes of the disorder is the nurse likely to note? Suicidal tendency. Underlying hostility. Delusions. Flight of ideas. In the depressed episode, anger is turned inward; in the manic, it is noted in sarcasm, demanding behavior, and angry outbursts. Answers 3 and 4 occur in the manic episode. Answer 1 is a particular problem in the depressed phase. Remember point of theory: depression may be anger turned inward as opposed to expressed outwardly (as in manic behavior). A patient who is overweight is referred by the physician to the nurse for diet counseling. What action would the nurse take? Develop a weight control plan, together with the patient, that will allow gradual weight loss. Ask the patient to describe his or her eating patterns. Support the patient's interests in other activities. Put the patient on a diet with very limited number of calories so he or she will have an immediate weight loss. The nurse should formulate a weight control plan, in cooperation with the patient, that allows for a gradual weight loss, not immediate loss as in Answer 4. Answers 2 and 3 are incorporated into Answer 1. When three options are good, choose the one that covers them all. Also look at two contradictory options: "gradual" vs. "immediate" weight loss. Choose the more realistic option ("gradual"). A patient begins having auditory hallucinations. When the nurse approaches, the patient whispers, "Did you hear that terrible man? He is scary!" Which would be the best response for the nurse to make initially? What is he saying? I didn't hear anything. What scary things is he saying? Who is he? Do you know him? I didn't hear a man's voice, but you look scared. This is a reality-based response, as well as one that acknowledges the patient's nonverbal reaction. The other choices are not the best because Answers 1 and 3 focus on "voice," which reinforces the hallucination, and no doubt is placed; in Answer 2 doubt is placed, but the focus is on "voice" and not on patient's feelings. Note the key word "initially," which includes reality orientation and patient's feelings. After seeing a number of doctors for nonspecific complaints of chest pains, with no conclusive findings of organic disease, a client is referred to a local mental health center. The client has read extensively about coronary disease and talks continuously about the symptoms in great detail. Which approach by the nurse would be best when meeting this client for the first time? Allow the client to describe the physical problems to become familiar with them. Comment on a neutral topic instead of using the usual conversation opener of "How are you today?" Give the client a simple but direct explanation of the physiological basis for the symptoms. Let the client know that the nurse is familiar with the psychogenic problems and guide the discussion to other areas. It shows acceptance by listening to the client's initial account of the physical problems. Neither a superficial focus nor a technical explanation of physical problems (Answers 2 and 3) conveys acceptance of the client as a person; Answer 4 is too abrupt for an initial response. Look at the verbs: "allow," "comment," "give," "let (the patient know)." Choose the one that most conveys acceptance. A 35-year-old married clerk had surgery for ulcerative colitis 3 days ago. The physical symptoms have abated, but he continues to complain angrily and to be demanding of the nursing staff. He makes numerous requests, such as to open or close the windows and to bring him fresh water. The nurse needs to understand that this behavior might be saying: You aren't doing your job. I am alone and helpless and need to depend on you to take care of me when I need you. Everyone needs attention. I'm going to get even with you for thinking I'm a crank by making you work. Characteristic underlying needs in somatoform disorders are dependency, attention, and the need for security through trust. Answers 1 and 4 are incorrect because the patient's complaints are not aimed at blaming others or at seeking vengeance but at expressing dependency needs and seeking security. Answer 3 is inappropriate because the patient is expressing his or her own need for attention; the patient is not speaking for everyone. Apply the process of elimination. Eliminate the two hostile options (1,4); next eliminate the global "everyone." The nurse is aware that the main function confabulation serves in clients, especially those with dementia, is to: Impress others. Protect their self-esteem. Control others by distance maneuvers. Maintain a sense of humor. Because confabulation is a coping mechanism, the best choice is the one that defines one of the main functions of coping mechanismsto protect self-esteem. Answers 1 and 3 are incorrect because they focus on others, not on self. Answer 4 is completely irrelevant. Choose the response that focuses on the patients, after eliminating two options that focus on others (1, 3). It's a "patient focus vs. others" type of tip. A 19-year-old patient is brought to the emergency department because she slashed her wrists. What is the nurse's first concern? Stabilization of physical condition. Determination of antecedent, causal factors relevant to the wrist slashing. Reduction of anxiety. Obtaining a detailed nursing history. Deal first with the lifesaving situation. Answers 2 and 3 are incorrect because they are done following stabilization of physical condition. Answer 4 is incorrect because it is not a necessary lifesaving concern. Note key words "first concern," which is a priority on Maslow's hierarchy of human needs (e.g., physiological needs). A patient who is agitated begins to shout insults and threats at others, and starts demolishing the recreation room. What is the best response or action by the nurse? Firmly set limits on the behavior. Allow the patient to continue, because the patient is seeking to express herself or himself. Tell the patient he or she is trying to intimidate other clients. Let the patient know that he or she does not need to express anger at the nurse by demolishing the recreation room. The nurse needs to set limits to ensure the safety of the patient and others. Answer 2 is incorrect because the patient may hurt herself or himself or others. Answers 3 and 4 are incorrect because they are interpretations that may or may not be correct, and they do not control the unsafe behavior. Look at two options that are contradictory ("allow" and "limits"). Because the main concern is safety when a patient is agitated, select Answer 1. Avoid interpretive statements (3,4). A second-grade girl starts at a new school, and the child's grades suffer while focusing on adjusting to new peers. The father severely reprimands the child and forces the child to study after school rather than play with other children. These data indicate to the nurse that this child is deprived of forming which normal phase of development? A love relationship with the father. Close relationships with peers. Heterosexual relationships. A dependency relationship with the father. In second grade a person needs to form close relation ships with peer Answer 1 needs to occur earlier than second grade or later in early teen years. Answer 3 occurs later. Answer 4 is incorrect because the father's actions make the child dependent on him rather than on peers. Know normal age-appropriate growth and development. The nurse is interviewing a teenage patient with acting-out behaviors. The teenager complains that no one will let him "do his own thing," and sits glaring at the nurse. What is the nurse's best response? I know you are angry, but how does being angry help? Stop being angry and tell me what is wrong. I think you are angry because you feel you don't need any help. We have to meet because your parents are concerned about you. This tells the teenager the nurse heard his statement about "not doing his own thing" and thinks he is angry. Answer 1 is incorrect because this states the nurse knows he is angry. Answer 2 is incorrect because an angry person can not stop being angry on command. Answer 4 is incorrect because focusing on the parents puts the nurse on their side. Choose a therapeutic communication response that focuses on the teenage patient's feelings (not "we," "your parents" as in Answer 4). A patient looks at a mirror and cries out, "I look like a bird. My face is no longer me." Which would be the best response by the nurse? Which bird? That must be a distressing experience; your face doesn't look different to me. Maybe it was the light at that particular time. Would you like to use another mirror? What makes you think that your face looks like a bird? This acknowledges the experience and points out reality as the nurse sees it. Answers 1, 3, and 4 do not focus on the patient or attempt to explore feelings. An effective response to hallucinatory behavior is to support the feeling aspect ("distressing") while also pointing out reality. A patient with ulcerative colitis and the patient's family are ready to make discharge plans jointly with the staff. Which assessment will have the greatest bearing on the patient's rehabilitation course? The amount of emotional support the family gives the patient. The spouse's interest in and ability to take care of the postoperative dietary needs. The family expectations of the patient to resume his or her role in the home. The spouse's understanding that the course of the illness may have exacerbations and remissions. Emotional support is a key need. Answer 2 does not focus on emotional support. Answer 3, role expectation, in itself has no bearing; emotional support of role would. Answer 4 would help the spouse and his or her own emotional reaction but would not help the patient. Best answer focuses on emotional support for the patient. Eliminate the three other options because they focus on the spouse or family. A 10-year-old child diagnosed with acute leukemia, terminal stage, asks the nurse one morning: "I am going to die, aren't I?" What would be the most appropriate response by the nurse? No, you're not. You are getting the latest treatment available and yon have a very good doctor. Your white count was better yesterday. We are all going to die sometime. What did the doctor tell you? I don't know. You have a serious illness. Do you have feelings that you want to talk about now? An honest, direct answer that focuses on feelings is the best approach. Answers 1, 2, and 3 stop any further exploration of the client's feelings. Choose the answer that helps explore feelings. Eliminate the other three options that close off communication and focus on facts, not feelings. For a patient with a diagnosis of a somatoform disorder, which would be the appropriate initial nursing goal? Help the patient learn how to live with the functional organic disturbance without using the symptoms to control others. Assist the patient in developing new and varied interests outside of himself or herself at which he or she can be successful. Accept the patient as a person who is sick and needs help. Help the patient see how he or she uses the illness to avoid looking at or dealing with problems. Showing acceptance and gaining trust and confidence are usually the key initial nursing goals. You need to show acceptance before helping (Answers 1 and 4) or assisting (Answer 2). Focus on the phrase "initial nursing goal," which is acceptance. Note the lead verb: accept before help or assist. An acutely ill patient hospitalized with metastatic lung carcinoma begs for a pass to attend her son's high school graduation in a city 100 miles from the hospital. "If only I could do this one thing, then I'll be ready to die," the patient says. The nurse identifies this behavior as an example of: Being unrealistic and denying the degree of illness. Using bargaining as a reaction to death and dying. Being manipulative to get the patient's way. Being unaware of the diagnosis. Refer to Elisabeth Kbler-Ross's emotional stages of death and dying. She is being neither unrealistic (Answer 1), manipulative (Answer 3), nor unaware of her diagnosis (Answer 4). Select the response that typifies a common grief reaction ("bargaining"); eliminate the three responses that have a negative tone ("deny," "manipulative," "unaware"). A patient who is overweight says to the nurse, "My therapist told me I eat because I didn't get enough love from my mother. What does the therapist mean?" What is the best response for the nurse to offer? Tell me what you think the therapist means. We are here to deal with your diet, not with your psychological problems. You need to ask your therapist. What do you think is the connection between your not getting enough love and your overeating? This reply asks for information that the nurse can use. If the patient understands the statement, the nurse can support the therapist when focusing on connections between food, love, and mother. If the patient does not understand the statement, the nurse can help get clarification from the therapist. Answer 2 alienates the client, and the nurse loses the chance for collaboration with the therapist. Answer 3 shuts the patient off. Answer 4 is incorrect because it is asked before the nurse is sure the patient understands the therapist's statement. Choose a therapeutic communication response that helps the patient give the nurse feedback (on patient understanding of therapist statement). An elderly patient who is hard of hearing repeats, over and over again, the same story of the patient's family coming "out West" in a covered wagon. Which interpretation by the nurse would not demonstrate understanding of this behavior? The patient has better recall for past events than for recent ones. The patient enjoys reliving the pleasurable aspects of life, because the present and future are bleak. Repeating stories is one way of interacting, to compensate for a two-way conversation that is difficult for the patient to sustain. The patient wants to impress others. Redundancy is not meant to impress others but is aimed at pleasure gained through focus on the past and need to control the conversation when memory or hearing deficit is present. Answers 1, 2, and 3 would demonstrate understanding of this behavior. Focus on the key phrase "not demonstrate understanding"; use a true-or-false approach. A nursing carp plan for a hospitalized hyperactive client in a manic episode must include: Involvement in a group activity and encouragement to talk. Attention to adequate food and fluid intake, Protection against suicide. Permissive acceptance of bizarre behavior. During a manic episode, the client may he too busy to eat and sleep. Answers 1 and 3 are more appropriate for a depressive episode; Answer 4 is more appropriate for schizophrenia with bizarre behavior. Clients in manic episode exhibit hyperactive behavior. Match characteristic behaviors with other main diagnostic categories: depression with Answers 1 and 3 and schizophrenia with Answer 4. The nurse finds an elderly patient with Alzheimer's in the hallway at 4:00 a.m., trying to open the door to the fire escape. Which response by the nurse would probably indicate the most accurate assessment of the situation? You look confused. Would you like to sit down and talk with me? That door leads to the fire escape. Why do you want to go outside now? This is the fire escape door. Are you looking for the bathroom? Something seems to be bothering you. Let's go back to your room and talk about it. Nocturnal urination is a most common need, complicated by disorientation related to the patient's age, disorder, and unfamiliar environment at night. To sit down (Answer 1) or to go back to the patient's room and talk (Answer 4) does not take care of the possible problem, the need to urinate. Asking a person "why" questions (Answer 2) is not helpful and is too literal a response to the behavior. Confusion (Alzheimer's) and age-typical physiological need (nocturia) call for a response that is reality orientation and environmental redirection (to the location of the bathroom). Since the death of her baby, a woman has lost weight, will not eat, spends most of her time immobile, and speaks only in monosyllabic responses. She pays little attention to her appearance. One afternoon, this patient comes to lunch with her hair combed and traces of lipstick. What could the nurse say to reinforce this change of behavior? What happened? You combed your hair! This is the first time I've seen you look so good. You must be feeling better. You look much better. I see that your hair is combed and you have lipstick on. A simple acknowledgment of what the nurse sees is the best response. Answer 3 makes an assumption that the patient feels better if she looks better. Answers 1 and 2 can be taken as a put-down. Eliminate put-downs and assumptions. Keep it simple (KIS) and simply acknowledge what the nurse observes. While the nurse is interviewing a teenage patient, the patient says, "I suppose you have to tell my parents everything." What would be the best response by the nurse? What are you going to tell me that is so secret that I can't tell your parents? If you tell me you are going to do something to hurt yourself I will have to tell your parents, but I will tell you first before I tell them. Everything you tell me is confidential. I will not tell your parents anything. Everything you tell me I will need to tell your parents. They have a right to know. Confidentiality cannot be guaranteed if there is a danger to the patient or to others. Answer 1 is incorrect because it is a sarcastic response and denies that the patient has serious problems. Answer 3 contradicts Answer 2. Answer 4 is incorrect because parents do not have the right to know the content of therapy sessions except in the circumstances described in Answer 2. Eliminate two options with the global "everything" and one option that can be seen as a put-down. In paranoid disorder, the part of the personality that is weak is called the: Id. Ego. Superego. Not me. A diagnosis of a paranoid disorder implies weak ego development. Answers 1,3, and 4 are incorrect because a client with a paranoid disorder might have strong id, super ego, and "not me" components. Focus on the word "weak" in the stem. A key consideration in planning the general care of clients with dementia is that: They be protected from suicide attempts. Their capacity for physical activity is diminished. Team effort be aimed at increasing their independence. The staff be sympathetic when clients mention their failing abilities. An important principle to remember here is that a program of care should not increase physiological losses by over taxing the client's physical capacities. It is important to remember that suicide is the main concern of depression and not a key concern of dementia, as in Answer 1. Empathy rather than sympathy (Answer 4) is a helpful behavior. Answer 3, increasing independence, is not realistic; maintaining it is. Apply the process of elimination. Eliminate Answer 4 because "sympathy" is not therapeutic; eliminate the unrealistic response in Answer 3; eliminate Answer 1 because it applies to depression, not to general care in dementia. A college student was doing exceptionally well and was complimented by her chemistry professor, who arranged for her to become his lab assistant and to do advanced research. Although very thorough in her work, when given constructive criticism this student becomes angry and stalks out of the lab for a few hours. The most plausible theoretical explanation is that the student: Knows she is right. Thinks the professor is jealous of her. Needs to feel and know that she is perfect. Feels anxiety as a result of a threat to her security and self-image. This is the all-inclusive answer. Answers 1,2, and 3 may be part of Answer 4. Choose the "umbrella" answer (i.e., most inclusive) when all four options are correct. One therapeutic nursing attitude is to be accepting and permissive. To convey this attitude most therapeutically, the nurse might: Wait for a client to initiate contact. Let the client make decisions. Ignore undesirable behavior. Meet the client at his or her level of functioning. If a particular client is nonverbal, for example, the nurse should not expect that client to function at a verbal level until ready. In Answer 1, if the nurse waits for a client who is withdrawn to make contact, it may not be helpful. In Answer 2, a client who is ambivalent may need assistance in making decisions. In Answer 3, the client's undesirable behavior may be adversely affecting others. Apply a reasoning "What if.." approach: "What if" a patient will not initiate, can't make decisions, and undesirable behavior can't be ignored?. The basic goal of nursing in a mental health setting is to: Plan activity programs for clients. Maintain a therapeutic environment. Understand various types of family therapy and psychological tests and how to interpret them. Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness. This is the most neutral answer by process of elimination. Answer 1 is mainly the function of a recreational-occupational therapist, although nurses participate. Answer 3 is usually filled by psychologists and social workers, and Answer 4 is carried out primarily by psychologists or statisticians, although nurses are involved. "Maintenance of a therapeutic environment" fits more readily into a nursing role by virtue of the number of hours per day a nurse spends with the clients on a unit, in comparison with the number spent by other professionals. Keep it simple (KIS) response; a mental health setting should keep a therapeutic environment. Which nursing intervention is inappropriate with a person who is expressing anger? Stating observations of the expressed anger Assisting the person to describe the feelings. Helping the person find out what preceded the anger. Helping the person refrain from expressing anger verbally. A person needs to be allowed to express anger appropriately. Answers 1, 2, and 3 are incorrect choices here because they are things the nurse assists a person to do when intervening in anger. Key word: "inappropriate. The client tells the nurse about the client's parents' impending divorce. The client said, "I couldn't believe that he was going to leave us for someone else." Which would be best for the nurse to reply? Was your mother expecting this to happen? Yes, go on. Did you cry? I can understand how you must feel. Offering a broad opening by giving a general lead is most therapeutic to elicit further description of the client's reaction and to clarify feelings, which were vaguely stated. Answer 1 is a switch of focus from the client to the mother. Answer 3 is nontherapeutic because a question that can be answered by yes or no often closes off further exploration. Answer 4 could be a helpful intervention but is premature acknowledgment before feelings have been elaborated. Choose the most therapeutic communication response: giving a broad opening, with a general lead to clarify feelings. A crisis intervention nurse meets with a young patient who was admitted after attempting suicide by slashing the wrists. The nurse's initial goal at this time is to: Determine the precipitating event, determine how many people are involved in the incident, and determine how angry the patient is. Determine if the patient has an immediate support system, determine what the people in the support system think of the patient cutting the wrists, and determine how angry the patient is. Determine the precipitating event, determine if the patient has an immediate support system, and assess the likelihood of immediate recurrence of the suicidal act. Assess the likelihood of immediate recurrence of the suicidal act. It incorporates all information a crisis intervention nurse needs immediately. Answers 1 and 2 are incorrect because the nurse does not need to know about other people's involvement at this time. Answer 4 is incorrect because it is not as complete as Answer 3. Key words: "initial goal. A client states, "The nofas are coming." In response to this neologism, it would be best for the nurse to: Divert the client's attention to an aspect of reality. State that what the client is saying has not been understood and then divert attention to something that is reality bound. Acknowledge that the word has some special meaning for the client. Try to interpret what the client means. It is important to acknowledge a statement, even if it is not understood. Answer 1 is not a direct response; Answer 2 leaves out the importance of the meaning of the neologism to the client; and Answer 4 is less valid and important than acknowledgment of the meaning to the client. Look at the verbs: "divert," "state," "acknowledge," "interpret." Select "acknowledge" as the first response. Which nursing approach is important in depression? Providing motor outlets for aggressive, hostile feelings. Protecting against harm to others. Reducing interpersonal contacts. Deemphasizing preoccupation with elimination, nourishment, and sleep. It is important to externalize the anger away from self. Answer 2 is incorrect because usually the client is turning anger inward, toward the self. Answer 3 increases the client's sense of isolation. The needs in Answer 4 should be emphasized, not deemphasized, because the depressed client often has somatic delusions. Apply a commonly accepted point of theory about depression: anger turned inward that needs to be externalized. One evening the nurse sees a client in the dayroom without any clothes, shouting vulgarities and dancing wildly about the room while other clients are watching TV. the best initial response by the nurse at this time would be: Let's sit down with the others and watch TV; I'll put this blanket over you to keep you warm. We do not allow this behavior in the hospital. It is embarrassing the other clients. Please put your clothes on. Come put your clothes on. I will help you. It is a matter-of-fact statement that is direct, while offering assistance and setting limits on inappropriate behavior. The other choices are not useful because Answer 1 reinforces inappropriate social behavior; Answer 2 sets limits but does not state a positive expectation for the client to follow; and Answer 3 neither offers assistance nor sets limits, which the patient needs. Pay attention to the phrase "best initial response." The nurse discovers a client crouched in a corner, looking pale and frightened, and holding a gushing wrist wound. A razor is nearby on the floor. What should the nurse do first? Sit down on the floor, next to the client, and in a quiet, reassuring tone, say, "You seem frightened. Can I help?" Ask the aide to watch the client and run to get the doctor. Apply pressure on the wrist, saying to the client, "You are hurt. I will help you." Go back down the hall to get the emergency cart. Take care of the bleeding (physical aspects of care) first. In Answers 1 and 2 the client could suffer extensive blood loss if the nurse focuses on feelings at this point or leaves the client without first attempting to control the bleeding. In Answer 4, the client is left alone, bleeding, frightened, and with a razor still at the side. Be aware that the stem asks for first action. Which characteristic should the nurse recognize as common in a person engaged in gradual self-destructive behavior (such as in obesity, drug addiction, and smoking)? Acceptance of the death wish. Denial of possibility of death. Ability to control own behavior. Ignorance of the consequences of own behavior. Persons engaged in self-destructive behavior other than active suicide behavior fantasize that they can control their behavior and deny the likelihood of death as a result. Thus Answers 1,3, and 4 are incorrect. Know theory about gradual self-destructive behaviors and eliminate the three that are theoretically incorrect (1,3,4). Look at two options that are opposites (acceptance and denial) and choose a most common defense mechanism (denial). A divorced woman learns that her ex-husband has died. Her reaction is stunned silence, followed by anger that he left no insurance money for their young children. The nurse should understand that: The woman is experiencing a normal bereavement reaction. To explain the woman's reaction, the nurse needs more information about the relationship and breakup. The children and the injustice done to them by their father's death are the woman's main concern. The woman is not reacting normally to the news. Shock and anger are commonly the primary initial reactions. Answer 2 is irrelevant. Answer 3 is a literal, concrete interpretation of the patient's reaction, not aimed at the possible latent feelings. Answer 4 is incorrect because it contradicts the correct answer, Answer 1. Look at two contradictory options (normal vs. not normal); review normal grief reactions and choose "normal. What will the nurse most commonly note in the clinical picture of dementia? Memory loss for events in the distant past. Quarrelsome behavior directly related to the extent of lack of blood supply to the brain. Increased resistance to change. Insight into one's situation, its probable causes, and its logical consequences. One of the main needs experienced by most clients with dementia is the need for most things to be the same. The other choices are wrong for the following reasons: there has been no demonstrable evidence of relationship between any behavior symptom and the extent or severity of pathophysiological condition (Answer 2); intellectual blunting usually occurs, which interferes with ability to deal with insight and abstract thoughts (Answer 4); and memory loss is for recent events and names, not those in the distant past, as in Answer 1. Key words: "most commonly. A man is hospitalized following a car accident in which his wife died, and he is unable to attend the funeral due to his severe chest injuries. What would the nurse consider in forecasting this surviving spouse's potential for difficulty with grief resolution? Feelings of anger toward the hospital staff for keeping him hospitalized during the funeral. Feelings of anger toward himself for having been injured but not killed in the accident. His inability to participate in the cultural rituals of grief, wherein the reality of his wife's death is emphasized. His preoccupation with his own physical distress at this time. One way to enhance the development of unresolved grief is not to participate in activities that demonstrate death. Answers 1, 2, and 4 may occur, but they are not the best predictors of grief resolution difficulties. Apply theory about unresolved grief (which may be related to lack of culturally sanctioned rituals for "letting go"). A patient who is depressed says, "I don't cry because my wife can't bear it." The nurse needs to be aware that this is an example of: Suppression. Undoing. Repression. Rationalization. Rationalization is the process of constructing plausible reasons for one's responses. Answer 1, suppression, is the intentional exclusion of material from consciousness. Answer 2, undoing, is an act that partially negates a previous one. Answer 3, repression, is the involuntary exclusion of painful or conflicting thoughts or feelings from awareness. Review definitions with clinical application of defense mechanisms. When interacting with clients who have autistic thinking and speaking patterns, what is likely to pose the greatest difficulty for the nurse? Showing acceptance for their incomprehensible acts and verbalizations. Ignoring their bizarre behavior. Speaking in a way that client can understand. Determining which of the clients' needs are being met by their autistic expressions. Decoding symbolic, autistic expressions calls for skill and sensitivity in understanding latent messages. Answer 1 is not a good choice, because showing "acceptance" is a basic, initial nursing goal that does not require a complexity of skills. Answer 2 points out a nontherapeutic nursing action, which is best not to use at all. Answer 3 implies that the nurse use short sentences with clear, concise, unambiguous meaning; this can be accomplished with practice. Answers 1 and 3 must be accomplished before Answer 4 is possible. Greatest difficulty is the key phrase to keep in mind. A patient refuses to eat meals in the hospital, stating that the food is poisoned. The nurse is aware that the patient is expressing an example of: Hallucination. Illusion. Delusion. Negativism. This is a false belief developed in response to an emotional need. In Answer 1, the situation is not a perceptual disorder. In Answer 2, the situation is not a misperception. In Answer 4, although the patient refuses meals, the reason for this is a false belief (delusion). Know the difference between a false belief, a misinterpretation, and misperception. An adolescent has a history of truancy from school, running away from home, and "borrowing" other people's things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand that psychodynamically, this behavior may be largely attributed to a developmental defect related to the: Id. Ego. Superego. Oedipal complex. This shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego. Answer 1 is incorrect, because the id is strong. These disorders are not characterized by a weak ego, as in Answer 2, whereas schizophrenia is. Answer 4 is of relevance in sexual-identity difficulties rather than in personality disorders. Sociopathic behavior and weak superego can be matched. Key word: "defect. What is the nurse likely to note in a patient being admitted for alcohol withdrawal? Perceptual disorders. Impending coma. Recent alcohol intake. Depression with mutism. Frightening visual hallucinations are especially common. Answer 2 is incorrect because coma is usually not an immediate consequence of alcohol withdrawal. Answer 3 is incorrect because the diagnosis is withdrawal from alcohol, not alcohol intoxication (intake). Answer 4 is incorrect because the patient will be agitated and rambling in conversation, not mute and depressed. Key words: "likely," "on admission," and "withdrawal. A patient says he must wash his hands from 9:00 to 9:45 a.m. each day and therefore cannot attend 9:00 a.m. group therapy sessions. Which concept does the nursing staff need to keep in mind in planning nursing interventions for this patient? Fears and tensions are often expressed in disguised form through symbolic processes. Unmet needs are discharged through ritualistic behavior. Ritualistic behavior makes others uncomfortable. Depression underlies ritualistic behavior. Anxiety is generated by group therapy at 9 A.M. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy. Answer 2 is incorrect because tension, not unmet needs, is discharged through ritualistic behavior. Answer 3 may be true, but it is not essential to planning care. Answer 4 is incorrect, because depression is not characteristic of ritualism. Apply theory about ritualistic behavior (also called obsessive-compulsive disorder, which is an anxiety disorder). "Fears" and "tensions" are similar to "anxiety. To formulate an effective care plan for a client with a somatoform disorder, the nurse needs to have an understanding of which related psychodynamic principle? The major fundamental mechanism is regression. An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention, and love. The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings. The client's symptoms are imaginary and the suffering is faked. Somatoform disorders provide a way of coping with conflicts. Answer 1 is incorrect because conversion, not regression, is the major coping mechanism. Answer 2 is incorrect because if a possible cause is identified and treatment relieves the discomfort, the client often develops another symptom. Frequently, clients do not want to be cured of their symptoms because they need the symptoms to control the behavior of others or because they do not know how else to get attention. In Answer 4, the converse is true: the symptoms are real, not imagined or faked. When in doubt as to the most theoretically correct answer, choose the option that has "feelings" in it. In evaluating a patient who has somatoform symptoms, the nurse is aware that the patient will probably show the most improvement when he or she: Accepts the fact that the physical symptoms have an emotional component. Finds more satisfying ways of expressing feelings through verbalization. Becomes involved in group activities and focuses less on the symptoms. Understands that the current way of reacting to stress is not healthy. All the other choices (1,3,4) are correct but can be dove tailed into Answer 2. Choose the "umbrella" answer that encompasses the other three choices. An important part of the nursing care for a client with dementia would be: Minimizing regression. Correcting memory loss. Rehabilitating toward independent functioning. Preventing further deterioration. Use of regression as a coping response can be minimized. Memory loss is usually permanent, not correctable; thus Answer 2 is wrong. However, disorientation attributed to loss of memory can be minimized. Clients usually become more dependent in the course of illness and deteriorate progressively. Thus Answers 3 and 4 arc incorrect. Know what can and cannot be ameliorated. Whereas the nurse cannot stop the pathological course of Alzheimer's disease (i.e., memory loss impermanent; deterioration is progressive and rehabilitation is not possible), use of a coping mechanism (regression) can be minimized. In explaining the goal of therapy in crisis intervention to a new colleague, the nurse states that the goal is to: Restructure the personality. Remove specific symptoms. Remove anxiety. Resolve immediate problems. The major goal of crisis intervention is to resolve immediate problems. Answer 1 is incorrect because restructuring personality is the goal of psychoanalytic therapy. Answers 2 and 3 are incorrect because they are goals of brief psychotherapy, and although they may occur in the resolution of immediate problems, they are not the goal. Note the similarity between the word "crisis" in the stem and "immediate" in the correct option. The steps in therapeutic nursing intervention with an angry client would be to describe the situation, then: Discuss alternative solutions, decide on several, try them out, and evaluate their effectiveness. Focus on one solution, try it out, and evaluate its effectiveness. Outline to the client exactly what to do about the anger. Discuss alternative solutions, decide on one, use it, evaluate its effectiveness, and continue repeating the process until the client is satisfied. It provides the complete steps. Answer 1 is incorrect because of the phrase "decide on several"; it should be one solution at a time. Answer 2 is incorrect because it does not include "discuss alternative solutions." Answer 3 is incorrect because it does not describe a requested series of steps and because giving a person one answer is untherapeutic. The best answer meets the condition of the stem: a series of steps in the therapeutic process. Answer 2 would be also a good choice, but it is incomplete (misses one step). Eliminate Answer 1 because it is an overload (i.e., several solutions); and eliminate Answer 3 because it is dictatorial, not a discussion. Therefore, first focus on the two options that have "discuss" and choose "one solution" at a time. On a routine physical, a woman learns she has a lump in her breast. It is found to be malignant, and a modified mastectomy is performed. Immediately following the surgery, what behaviors could the nurse expect this patient to display? Signs of grief reaction. Signs of deep depression. Relief that the operation is over. Denial of the possibility of carcinoma. It is most likely that grief would be expressed because of object loss. Answer 2 is incorrect because deep depression, if it occurs, would be the result of lack of resolution of grief over object loss. Answer 3 is incorrect because relief is not part of the grief process. Answer 4 is incorrect because the question asks for the client's immediate response. Denial of carcinoma, if it occurs, would probably occur later. Note the word "immediately" following the surgery. A 19-year-old patient's over compliance with his parents' expectations for his behavior could result in: Lack of development of a separate identity. Confusion of his sex role. Successful development of a separate identity. Identification of a weak superego. Overcompliance leads to lack of development of self-identity, one of the major problems in schizophrenic disorders. Answer 2 is incorrect because there are no substantiating data. Answer 3 is incorrect because it contradicts the correct statement in Answer 1. Answer 4 is incorrect because the patient probably has a strong superego due to an implied "should" system (over compliance with parents' expectations of behavior). Look at two contradictory options: "lack of separate identity" vs. "a separate identity. A doctor asks the nurse to activate a patient who hears voices and is withdrawn and negativistic. What would be the nurse's best approach? Give the patient a long explanation of the benefits of activity. Tell the patient that the nurse needs a partner for an activity. Demand that the patient join a group activity. Mention that the "voices" would want the patient to participate. The nurse helps to activate by doing something with the patient. Answer 1 is incorrect because the patient will not hear a long explanation. Answer 3 is incorrect because demanding will not work; the patient cannot join in unless you are with the patient (as in Answer 2). Answer 4 is incorrect because you should not produce psychosis to motivate a person. Look at key words in the options and eliminate the three worst: "long explanation"; "demand"; "voices want the patient. When an experiment in the laboratory goes wrong, a researcher complains of a plot against her, and accuses the lab assistants of sending signals about her to each other. The nurse would determine that this behavior is related lo: Delusions of grandeur. Illusion. Ideas of reference. Echolalia. The meaning of "ideas of reference" is that all that goes on is somehow connected to a person. Answer 1 is incorrect because delusions of grandeur mean a person has an exalted opinion of self. Answer 2 is incorrect because illusion is a false perceptual experience occurring in response to a stimulus. Answer 4 is incorrect because echolalia is a person's automatic repetition of what is said. You can apply the correct term if you understand what the terms mean. A teenager with acting-out behaviors says to the nurse, "I want you to go tell the teacher I am sick and I am to be allowed to do what I want." The nurse determines that this statement best represents: Insight. Manipulation. Dependency. Trust. Manipulation is the attempt to control the behavior of others to achieve one's own goals. Answer 1, insight, is understanding and using understanding to correct one's behavior. Answers 3 and 4 are incorrect because although the client may be trying to con the nurse into believing he or she needs the nurse to do something for him or her and the client trusts the nurse, the real purpose of the request is manipulation. Review the concept of manipulation. Eliminate three options that have no relationship to "acting out" (insight, dependency, trust). A 52-year-old patient who appears lucid learns that after surgery, he will wake up in the recovery room without his thick glasses and hearing aid. He immediately states that without these he will be confused and upset. The nurse determines that the patient is trying to say that he: Has periods of confusion and may have a psychiatric problem. Is psychologically dependent on the hearing aid and glasses. Needs the hearing aid and glasses to correctly perceive what is going on around him, and misperception will cause confusion. Needs the hearing aid and glasses because he wants to be sure people are taking proper care of him. A person with limited hearing and sight becomes confused and disturbed. Answers 1 and 4 are unwarranted assumptions. Answer 2 is incorrect because the patient's situation is not psychological dependency but actual sensory need. Choose the most reasonable explanation and avoid making assumptions (1,4). A patient relates angrily to the nurse that his wife says he is selfish. Which would be the most helpful response by the nurse? That's just her opinion. I don't think you're that selfish. Everybody is a little bit selfish. You sound angrytell me more about what went on. It is important to pick up on a feeling tone and encourage exploration of the feelings and the situation. Answer 1 stops exploration of the patient's feeling. Answers 2 and 3 shift the focus away from feelings to content of selfishness. Focus on feelings and encourage elaboration, with an open-ended statement ("tell me more about.."). When a client has dementia, it is most important that the nurse plan the daily activities to: Be highly structured. Be changed each day to meet the client's needs for variety. Be simplified as much as possible to avoid problems with decision making. Provide many opportunities for making choices to stimulate the client's involvement and interest. Clients with dementia feel more secure when they can count on their environment being the same, predictable, and consistent in detail from day to day (hence, structured) to compensate for feelings of loss of the familiar in terms of body functions, social environment, and so on. Answers 2 and 4 imply change, not routine. Answer 3, although correct, is not the most important. Two options are correct (1,3). When the activities are structured (the best response), they are usually also simplified and avoid decision-making problems. This is a "telescope" answer, in which a broader option subsumes a narrower one. A woman tells the nurse that she refuses to eat her husband's cooking because she thinks he is poisoning her. The nurse is aware that this behavior is related to: Delusion of persecution. Ideas of reference. Illusion. Hallucination. The patient has ideas that someone (her husband) is out to kill her. Answer 2 is incorrect because the problem is beyond just an "idea of reference" (she fears bodily harm). Answer 3 is incorrect because illusion is a false perceptual experience occurring in response to a stimulus. Answer 4 is incorrect because a hallucination is a sensory experience triggered by a person's inner needs, functioning independently of stimulation from the environment. Know your terminology to spot the only correct answer. The crisis nurse explains to a colleague that the focus of treatment in crisis intervention is on the: Present and on restoration to the usual level of functioning. Past and on freeing the unconscious. Past in relation to the present. Present and on the repression of unconscious drives. To resolve immediate problems, focus on a person's ability to cope and usual level of functioning. Answer 2 is incorrect because it is a psychoanalytic focus. Answers 3 and \ are incorrect because they are the focus of brief psychotherapy. Crisis focuses on the present and restoration of here-and-now coping. A patient in the postoperative period following surgery for ulcerative colitis suddenly becomes angry with another patient who is monopolizing the group therapy meeting. Which interpretation of this noted change in behavior would indicate that the nurse understands the dynamics of this patient's somatoform disorder? The patient is intolerant of others. The patient has strong competitive drives. The patient has his or her own ideas of how the group members should act. The patient is repressing fewer feelings. One coping mechanism often seen in somatoform disorders is repression. As the patient is better able to handle the anxiety connected with underlying feelings, the need for repression lessens. Answers 1,2, and 3 may be the content of the patient's feelings, but they do not explain the dynamics, the reason the patient is expressing more feelings. Note the key word: "dynamics." Separate content from dynamics to choose the best answer. A client has a somatoform disorder, paralysis of the arm. It would not be helpful for the nurse to use logic and reason to divert this client's attention from this physical state because: The client is not in contact with reality and thus is unable to "hear" or understand the nurse. The client may need the symptoms to handle feelings of guilt or aggression. The nature of the client's particular illness makes the client suspicious of all medical personnel. Paralysis of the arm has become a habitual response to stress. This disorder is an attempt to cope with stress and is a better choice than Answer 4, which may be true but is a tangential and irrelevant reason. Answer 1 is not correct because the client is aware of reality but may not understand the cause for the somatoform disorder. Answer 3 is more relevant in a paranoid reaction. Look for the statements that correctly explain somatoform disorders (2,4); eliminate Answer 4 because it is incorporated in Answer 2. While communicating with a patient who is withdrawn, what would be important for the nurse to do at first? Remain silent and not encourage the patient to talk. Talk with the patient as one would to a normal person. Allow the patient to do all the talking. Use simple, concrete language in speaking to the patient. Patients with withdrawn behavior in schizophrenic disorders tend to think in concrete terms. Therefore, use of simple language enables them to grasp meaning. Answer 1 is incorrect because if the nurse remains silent the patient will remain silent. Answer 2 is incorrect because if the nurse is not concrete the patient might have trouble understanding some terms in normal conversation. Answer 3 is incorrect because the patient has difficulty talking. KIS means keep it simplei.e., "simple .. language. The nurse bases a plan of care on the knowledge that persons engaged in gradual self-destructive behavior: Believe they can stop this behavior at any time. Have decreased anxiety when they stop the behavior. Believe the behavior controls them. Believe the behavior, in some manner, is "good" for them. These persons have not faced up to the idea that they are controlled by their behavior, and this relieves their anxiety. Contrary to Answer 2, persons have increased anxiety if they stop the behavior. Answer 3 is also incorrect because they fantasize that they control their behavior. Answer 4 is incorrect because these persons know the behavior is not "good" for them. Eliminate the three options that are opposite of correct points of theory. When a patient with symptoms of severe depression says to the nurse, "I can't talk; I have nothing to say," and continues being silent, what should the nurse do? Say, "All right. You don't have to talk. Let's play cards, instead." Explain that talking is an important sign of getting well and that the patient is expected to do so. Be silent until the patient speaks again. Say, "It may be difficult for you to speak at this time; perhaps you can do so at another time." Meet the patient at her or his level of functioning, and provide support and encouragement for a higher level in the near future. Answer 1 implies that the nurse agrees that the patient has nothing to say. Answer 2 conveys no empathy or understanding. Answer 3 is incorrect because silence reinforces silence and a sense of isolation. The best answer acknowledges feelings and is supportive, without reinforcing the silence. When talking with a client who is exhibiting a manic episode with flight of ideas, the nurse primarily needs to: Speak loudly and rapidly to keep the client's attention, because the client is easily distracted. Focus on the feelings conveyed rather than the thoughts expressed. Encourage the client to complete one thought at a time. Allow the client to talk freely. Often the verbalized ideas are jumbled, but the underlying feelings are discernible and must be acknowledged. Flight of ideas should be curtailed; thus Answer 4 is incorrect. The client may not be able to control the internal stimuli to focus on one idea at a time as in Answer 3. A louder and more rapid tone by the nurse may only increase the external stimuli for the client, making Answer 1 incorrect. Choose the answer that focuses on feelings. A patient says to the nurse, "I was going to kill myself last night." What is the best initial response by the nurse? Say nothing. Wait for the patient's next comment. What were you going to do this time? Have you felt this way before? You seem upset. I am going to be here with you; perhaps you will want to talk about it. The patient needs to have his or her feelings acknowledged, with encouragement to discuss feelings, and be reassured about the nurse's presence. The patient may interpret the nurse's silence as discomfort in talking about suicidal feelings and thoughts (Answer 1). Answer 2 focuses on facts too swiftly without providing an opportunity for the patient to express feelings. Also, Answer 2 would be most appropriate in crisis intervention when the patient is, first admitted, not the next morning. Answer 3 moves away from focus on here-and-now to focus on the past. Choose the answer that focuses on acknowledging feelings. Which feeling is the nurse likely to identify as antecedent of self-destructive behavior? Omnipotence. Grandiosity. Low self-esteem. Self-satisfaction. When feelings of low self-esteem are prevalent, self-destructive behavior reaches its peak. Hence, Answers 1,2, and 4 are incorrect. Low self-esteem is the option that is different from the three other options (omnipotence, grandiosity, self-satisfaction). Resolution of grief related to death is likely to be complicated when: There are ambivalent feelings for the deceased. The death was due to a chronic illness. It is the first loss to be experienced. There was little emotional dependency on the deceased. Love-hate feelings take longer to resolve. Reactions to loss tend to be cumulative in effect, in that the more loss experienced in the past, the greater the reaction the next time; thus Answer 3 is wrong. Reactivation of feelings connected with previous losses by the current loss accounts for the increased intensity of the reaction. Sudden, unexpected death, rather than death due to a chronic illness, as in Answer 2, is harder to resolve, and strong, not little, emotional dependency (as in Answer 4) also complicates grief resolution. Apply your knowledge about grief theory to choose the only correct answer. Which behavior might the nurse expect from a patient with congestive heart failure who is in the grief stage of developing awareness of the loss of a spouse? Crying, anger, or both. Appearing dazed and repeatedly saying, "No, it can't be." Preoccupation with thoughts of how ideal the marriage had been. Responding with a brief complaint about the patient's own physical pain. These behaviors are correct according to Lindemann's and Engle's grief stages. Hence, incorrect are Answer 2 ("shock" stage), Answer 3 ("idealization" stage), and Answer 4 ("resolving the loss" stage). Review stages of grief to choose the correct stage. What feeling tone is the nurse most likely to see the client demonstrate during major depression with psychotic features? Suspicion. Agitation. Loneliness. Worthlessness. Feelings of worthlessness or low self-esteem are the underlying problem in depression. Answers 1,2, and 3 may occur but are not most apt. Note key phrase: "most likely to see. When a client's behavior is considered abnormal, the nurse first needs to: Ignore the client. Serve as a role model. Point out the client's disturbed behavior. Focus on the feelings communicated by the client's behavior. Focusing on feelings is usually the best choice. Ignoring the client is rarely an acceptable intervention (Answer 1). Pointing out disturbed behavior and role modeling by the nurse are valid, but not as first interventions (Answers 2 and 3). Key words: "first need. A hospitalized patient cannot find his slippers and accuses other patients and staff of stealing them. The most therapeutic approach is to: Listen without reinforcing the patient's belief. Logically point out that the patient is jumping to conclusions. Inject humor to defuse the intensity. Divert the patient's attention. Listening is probably the most effective response of the four choices. A key consideration in interacting with patients who are suspicious is to avoid the use of logic and argument; thus Answer 2 is incorrect. Humor usually intensifies the anger and suspicion; thus Answer 3 is incorrect. Changing the topic, as in Answer 4, may serve to reinforce the patient's belief in the guilt of others. Choose the term that involves the least action and does not reinforce suspicious behavior. In interacting with a patient with an antisocial personality disorder, what would be the most therapeutic approach? Reinforce the patient's self-concept. Gratify the patient's inner needs. Give the patient opportunities to test reality. Provide external controls. Personality disorders stem from a weak superego, implying a lack of adequate controls. Answer 1 is not relevant, as the patient's self-identity is not a focus here. Answer 2 is incorrect because the patient typically gratifies his or her own inner needs; this is part of the difficulty with a strong id, and requires external controls as in Answer 4. Answer 3 is incorrect because the patient is not psychotic, but has a personality disorder for which reality testing is not impaired. The patient is aware of reality. Test taking tipApply knowledge about antisocial behavior to select the only correct answer, and to eliminate the three that are theoretically incorrect. To relate therapeutically with a patient who is dependent on alcohol, it is important that the nurse base his or her care on the understanding that alcohol dependence: Is hereditary. Is due to lack of willpower and true remorse. Results in always breaking promises. Cannot be cured. Arrest of the disease is possible through abstinence, not through change in psychophysiological response to alcohol. Answers 1,2, and 3 are stereotyped statements, not generally or universally accepted. Choose the least controversial belief: that alcohol dependence cannot be cured. Eliminate the option that has "always"; eliminate the option that is a clich (Answer 2); it has not been universally accepted that alcohol dependency is hereditary. A patient uses repetitive hand washing. To help the patient use less maladaptive means of handling stress, the nurse could: Provide varied activities on the unit, because change in routine can break this ritualistic pattern. Give the patient unit assignments that do not require perfection. Tell the patient of changes in routine at the last minute to avoid buildup of anxiety. Provide an activity in which positive accomplishment can occur so the patient can gain recognition. The opposite of what is stated in the first three choices is true. The patient seems to do best when routine activities are set up and anxiety-provoking changes are avoided (Answer 1); perfection-type activities bring satisfaction (e.g., cleaning and straightening a linen closet) (Answer 2); and the patient knows ahead of time about changes in routine (Answer 3). By knowing, understanding, and applying theory about dynamics of ritualistic behavior, you can eliminate three options that are theoretically inaccurate. You can also make an educated guess and choose as the best option the answer that includes the phrase "positive accomplishment can occur. The most common coping mechanisms used in somatoform disorders are: Repression and symbolism. Sublimation and regression. Substitution and displacement. Reaction formation and rationalization. The original source of conflict, pain, or guilt is repressed (pushed out of awareness), only to surface in a symbolic way. Answers 2,3, and 4 are only partially correct: in somatoform disorders, regression is common, not sublimation; displacement is common, not substitution; reaction formation is common, not rationalization. To serve as the best answer, all parts must be correct, not just partially correct. Review coping mechanisms as they relate to somatoform disorders. A patient who has been hospitalized with ulcerative colitis asks the doctor about the prognosis. The patient becomes alternately depressed and agitated when hearing of the impending discharge. Which nursing approach would be best at this time? You are much better than when you first were hospitalized. You have to decide whether you need to be hospitalized longer or whether you are ready to go home. You seem to have concerns about going home. What is it about going home that bothers you? You seem sad about going home. Would you like to talk about it? It reflects the patient's underlying concerns in the most open-ended manner. Answer 1 is incorrect because the nurse cannot say how the patient is feeling; this assumes here that the patient is better, which is inappropriate. Answer 4 focuses on only one aspect: sadness. What about the agitation the patient also expresses? Answer 3 is not incorrect, but it is also not the best choice because it asks a direct question when a simple acknowledgment (as in Answer 2) would be better initially. KIS (Keep It Simple); a simple acknowledgment is the most open-ended communication approach. Eliminate Answers 3 and 4 because they require the patient to answer. Eliminate Answer 1 because it is an overload. It is important for the nurse to be aware that the mental health of an aged client is most directly influenced by: The attitude of relatives in providing for the client's needs. Societal factors such as role change, loss of loved ones, and loss of physical energy. The client's level of education and economic situation. The attitudes the client has toward life circumstances. Although all the other choices (1,2,3) are valid and important, Answer 4 encompasses them all and is therefore the most comprehensive answer. Test taking tipWhen all four options are correct, choose the "umbrella" answer that includes them all. In crisis intervention therapy, the nurse plans her or his goals based on the principle that crises: May go on indefinitely. Seldom occur in normal people's lives. Usually are resolved in 4-6 weeks. Are related to deep, underlying problems. Part of the definition of a crisis is a time span of 4-6 weeks. Answer 1 is incorrect because by definition, crises do not continue indefinitely. Answer 2 is incorrect because all people have crises, and having crises does not determine abnormality. Answer 4 is incorrect because although crises may be related to deep, underlying problems, one of the principles of crisis intervention therapy is to deal with the immediate situation, not the underlying problem. By definition, crisis are short term. Look at two contradictory options: "indefinitely" vs. short term ("4-6 weeks"). The nurse can determine that the expression of hostility is appropriate and useful when the: Energy from anger is used to accomplish what needs to be done. Expression intimidates others. Degree of hostility is less than the provocation. Expression of anger dissipates the energy. This is the proper use of anger. Answer 2 is incorrect because although anger can be used to intimidate others, that use creates interpersonal problems. Answer 3 is incorrect because in order for hostility to be a helpful communication mechanism, the degree of hostility must be appropriate to the provocation. Answer 4 is incorrect because this expression of anger does not produce positive accomplishment. The best answer is usually the most understandable, with a positive tone, and free of jargon. Answer 2 has a negative tone ("intimidate others"); Answers 3 and 4 are confusing as to meaning. Two days after a mastectomy, a woman is crying and saying, "My husband won't love me anymore." The nurse is aware that this statement might stem from: The woman's deep insecurity about her marriage. Preexisting marital disharmony. The woman's concerns about her body and a resultant change in her beliefs about her own self-worth. A momentary fear about her husband's fidelity. A change in body image has made the patient feel unloved and unworthy of love. Answers 1,2, and 4 are incorrect because there are no supporting data. Eliminate the three options in which there is lack of information in the stem to support data about problems in the marriage. The best option centers on the patient and her self-concept. The nurse establishes a nurse-client relationship with a patient with a schizophrenic disorder. One of the goals is to help the patient develop a separate self-identity. One way to do this is to: Call the patient by a "pet" name frequently. Use "you" and "I" rather than "we." Correct the patient's opinions. Encourage "should" responses. Use of "you" and "1" forces the patient to acknowledge separate identities. Answer 1 is incorrect because "pet" names are usually not a person's choice. The patient needs to be called by his or her real name. Answer 3 is incorrect because the patient has no identity it he or she cannot have his or her own opinions. Answer 4 is incorrect because "should" responses imply others' ideas, not the patient's. The best answer ("you" and "I") reflects the stem: separate self-identity. Keep it simple (KIS) by selecting the obvious answer. A patient is diagnosed as having a paranoid disorder. What implication might this have for the nurse? Let the patient talk about her or his suspicions without correcting misinformation. Avoid talking to other nurses when the patient can see them but cannot hear what is being said. Placate the patient by agreeing with what he or she says. Argue with the patient about his or her ideas. A patient with paranoid disorder is suspicious, so a nurse must make every effort not to engage in behavior the patient can misinterpret. Answers 1 and 3 are incorrect because a nurse should give correct information about what the patient says and not placate him or her (the patient will sense the falseness). Answer 4 is incorrect because arguing just solidifies the patient's ideas. In a neutral voice, the nurse should give correct information. Review interventions with paranoid behavior to choose a response that minimizes distortions and avoids reinforcing the pathology. A teenage patient says to the nurse, "I want you to go tell the teacher I am sick and I am to be allowed to do what I want." What is the nurse's best response? Certainly. You are sick and need some relaxation of rules in the classroom. I am glad you recognize you are sick. No, you are expected to follow the rules of the classroom. All teachers are too strict. I agree some rules need to be relaxed. This response stops the manipulation and suggests the patient is responsible for his or her own behaviors. Answers 1, 2, and 4 are incorrect because they indicate that the nurse has been conned and manipulated. First, recognize manipulative behavior; next, rule out the three options that may play into this. A 50-year-old patient says he needs his glasses and hearing aid with him in the recovery room after surgery, or he will be upset and confused. What is the nurse's best response? You won't need your glasses or hearing aid. The nurses will take care of you. I understand. You will be able to cooperate best if you know what is going on, so I will find out how I can arrange to have your glasses and hearing aid available to you in the recovery room. I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know. Do you get upset and confused often? The patient will be easier to care for if he has his hearing aid and glasses. In Answer 1, the nurse is denying the patient his right to the full information of his senses. Answer 3 is incorrect because the nurse has the responsibility to change rules for clearly therapeutic reasons. Answer 4 does not respond to the patient's needs. Choose the option that starts with "I understand" and in which the nurse takes on a patient advocacy role. A mother talks about her daughter, who is mentally retarded: "She's really an inspiration to me, do you know what I mean?" Which would be the most appropriate initial comment by the nurse? What makes her an inspiration? It seems to be important to you to find something positive about her. No, explain more about what you mean. Tell me more about her. An appropriate direct response to a "you know what I mean" comment is to say you do not automatically know what is meant. Answers 1,2, and 4 are not the best response because they shift the focus from the client's experience to the characteristics of the other person. First, choose the answer that directly relates to the mother's question; then, seek clarification. At the first therapy session with a patient who recently attempted suicide, what does the crisis nurse need to do? Discourage discussion of the suicide attempt. Encourage the patient to focus on feelings about how badly the patient was treated as a child. Encourage the patient to discuss the suicide attempt in detail. Help the patient see how the suicide attempt hurt others. The patient needs to be aware of his or her actions and the possible ramifications of those actions. Answer 1 is incorrect because the patient needs to discuss the actions. Answer 2 is incorrect because the purpose of crisis intervention is to deal with the present problem and situation, not the past. Answer 4 is incorrect because the focus must be on the patient, not on others. First note the two options that are similar ("encourage") and one that is the opposite ("discourage"). Next, compare the difference between the two "encourage" options: one focuses on the past ("as a child") and the other on the here-and-now (recent suicide attempt). Choose the latter option. A mother says to the nurse, "When my baby had asthma 5 years ago, I thought he was going to die." What would be most appropriate for the nurse to say? What made you think that he was going to die? What did you do? You thought he was dying? What were some of your feelings at that time? Attempts to focus on encouraging the client to describe feelings are important. Answers 1 and 2 ask for facts rather than focusing on feelings, and Answer 3 is an example of reflectinga therapeutic response, but in this case it only reflects a thought, not a feeling. Choose the feelings-oriented option. In preparing the nursing care plan for an elderly man, the most common basic need that must be met is: Sexual outlet and security. Unconditional acceptance by others of his impairments and deficits. Preservation of self-esteem. Socialization. Self-esteem is the most basic psychological need at any age, especially so for the elderly. Answers 1,2, and 4, although also important, are not the most basic needs. When you see an option that has "self-esteem," go for it! One effective way for a nurse to start an interaction with a client who is silent is to: Tell the client something about himself or herself and hope that the client does the same. Remain silent, waiting for the client to bring up a topic. Bring up a controversial topic to elicit the client's response. Introduce a neutral topic, giving the client a broad opening. This is the least threatening. Answer 2 is incorrect because the nurse needs to intervene into a pattern of silence. It is not therapeutic for the focus to be on the nurse, as in Answers 1 and 3, and bringing up a controversial topic (such as religion or politics) usually results in an exchange of opinions and arguments. The words "neutral" and "broad opening" in Answer 4 lead you to the best answer. What would be the most realistic statement a nurse could make about a patient's prognosis after a course of necessary treatment for ulcerative colitis? The symptoms will recur. The ulcerative lesions will heal, but under stress the same symptoms will reappear. It is not possible to prognosticate the future course. Ongoing psychotherapy is essential for the patient to be free of symptoms. This answer is the best choice because the other choices (1,2,4) seem too certain for a disorder that, although it has a pattern, can be altered if and when the patient adopts different outlets for expressing emotions. Choose the most plausible, tentative response here rather than the three definitive ones ("will," "essential"). What might be the most therapeutic response the nurse could make to a student who begins crying on hearing that he or she failed an exam? You'll make it next time. Failing an exam is an upsetting thing to happen. How close were you to passing? It won't seem so important 5 years from now. This response picks up a "here-and-now" underlying feeling tone. Answers 1 and 4 focus on "there-and-then" rather than "here-and-now" feelings and events, and Answer 3 is irrelevant because the focus is on a fact rather than a feeling. Focus on feelings. Eliminate two options with clichs (1,4) and the option that avoids feelings by asking a factual question. Which adaptive behavior by a client with somatoform disorders might indicate to the nurse the greatest improvement in the client's condition? The client recognizes that the behavior is unreasonable. The client agrees to go to occupational therapy and recreational therapy every day. The symptoms are replaced by expressions of hostility. The client is verbalizing feelings instead of demonstrating them by pathological body languages. Expressing feelings in general through verbalization is a desired outcome. This answer also incorporates a specific feeling in Answer 3. Agreement to attend activities (Answer 2) does not indicate the greatest improvement. The client already recognizes that the behavior is irrational but cannot understand the cause or banish the behavior by will, as in Answer 1. When two answers could be correct, choose the one that incorporates both. A client tells the nurse that he has something he wants to say but does not want the nurse to tell anyone else. The nurse should: Agree not to "tell." Refuse to agree to this. Say nothing, allowing him to go on. Let him know that the nurse cannot promise this. Information that is given to the nurse that may interfere with the client's recovery must be related to other team members. The other choices are not the best response because Answer 1 is withholding information from other staff members who are also responsible for care and may interfere with recovery needs; Answer 2 is a refusal that may stop the interactiona negotiation is needed; and Answer 3 does not provide a client with the clear feedback needed to work through conflict. The best answer calls for knowledge about the concept of confidentiality. Which is an example of limit setting as an effective nursing intervention in ritualistic hand-washing behavior? I don't want you to wash your hands so often anymore. If you continue to wash your hands so frequently, the skin on your hands will break down. You may wash your hands before the group therapy meeting if you wish, but not during group therapy. The doctor wrote an order that you are to stop washing your hands so often. This is the best example of setting limits on the behavior. Answers 1 and 4 may be closely linked to nontherapeutic use of power. Answer 2 is more of an example of a punishment approach. You can readily eliminate the three negative options (nurse power in Answer 1; threatening sounding in Answer 2; MD power in Answer 4). Which nursing intervention is effective when clients are severely anxious? Encourage group participation. Give detailed instructions before treatment procedures. Impart information succinctly and concretely. Increase opportunities for decision making. Brief and specific information can be processed during severe anxiety. In severe anxiety, the person cannot respond to the social environment (as in Answer 1); giving detailed information results in overload, because the client cannot retain and recall data (as in Answer 2). Only directive information that is brief and specific is effective when the client cannot focus on what is happening. Decision making needs to be postponed until the person is less anxious; hence, Answer 4 is wrong. The severely anxious person needs to have "KISS" communicationKeep It Simple and Succinct. A nursing care plan for a patient with a history of alcohol abuse and dependency must incorporate which physical consequence? Cardiac arrhythmia. Convulsive disorder. Psychomotor hyperactivity. Cirrhosis of the liver. The liver is affected by both the direct effect of alcohol and nutritional deficiencies associated with alcohol abuse and dependence. Answers 1,2, and 3 are areas not usually affected by alcohol abuse and dependence. Review physiological consequences of alcohol abuse. When a client tells the nurse that he or she cannot sleep at night because of fear of dying, what would be the best initial response? Don't worry, you won't die. You're just here for some tests. Why are you afraid of dying? Try to sleep. You need the rest before tomorrow's test. It must be frightening for you to feel that way. Tell me more about it. Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings. The other choices are not the best response because Answer 1 is false reassurance that does not allay feelings; Answer 2 is asking a "why" question, which is confrontative and may increase anxiety; and Answer 3 gives advice, which stops exploration of underlying feelings. The best answer focuses on feelings. Review and eliminate examples of nontherapeutic communication. A new nurse is assigned to take clients for an outing. A patient with an antisocial disorder approaches the nurse and says, "I like you. I'm glad you'll be the one to take us out. My doctor told me that I can go too." Which initial response by the nurse is best? Since I am new here and not familiar with unit routine, I will go check with the staff and be back. It's a beautiful day, and I'm glad that yon have ground privileges now. When did the doctor tell you that? You seem pleased. This response aims to prevent use of manipulative patterns. In Answers 2,3, and 4, the nurse needs to seek validation, and these responses indicate acceptance without validation. The team approach for consistent reinforcement of rules is needed when interacting with patients who display manipulative behavior. Which common physiological reaction occurring in response to anxiety is the nurse likely to note? Clammy hands and increased perspiration. Palpitations and pupillary constriction. Diarrhea and vomiting. Pupillary dilation and retention of feces and urine. Answer 1 is the best choice because these are typical symptoms/responses to anxiety. Other common reactions are pupillary dilation, not constriction (Answer 2); diarrhea, not constipation (Answer 4). Vomiting is not typical of an anxiety response (Answer 3). Review physiological manifestations of anxiety. Clients with paranoid behavior use projection. The nurse is aware that this mechanism is chiefly a way to: Provoke anger in others. Control delusional thought. Handle their own unacceptable feelings. Manipulate others. This response refers to the definition of projection as a coping mechanism (attributing one's own unacceptable thoughts, feelings, and behaviors to another). Answers 1,2, and 4 are incorrect because they have nothing to do with the coping mechanism of projection. Coping mechanisms in general function in the service of "self"that is, they protect the ego and preserve self-esteem in an effort to cope with anxiety; the focus is not on others, as in Answers 1 and 4. Symptoms of projection do in fact express delusional thought rather than control it, contrary to Answer 2. Select the option that has "feelings. Which most characteristic behavior of a panic response is the nurse likely to note? Goal-directed behavior aimed at a "flight" from apparent threat. Automatic behavior with poor judgment. A severity of reaction that is not related to the severity of the threat to self-esteem. A delayed reaction in perceiving the danger. In panic, a person is highly suggestible and follows "herd instinct" rather than exercising independent judgment and goal-directed problem solving (Answer 1). Answer 3 is incorrect because the severity of the reaction is related to the severity of the threat. The more severe the perceived threat (actual or imaginary), the more intense the reaction to the danger, and not delayed as in Answer 4. Apply knowledge about panic reaction. At limes, a client seems preoccupied with her own thoughts as she grins, giggles, grimaces, and frowns. Although she is 23 years old, her behavior seems childish and regressed. She is unkempt, voids on the floor, disrobes, and openly masturbates. The main nursing care at this time should be directed toward: Improving the client's social conduct to meet hospital standards. Controlling the narcissistic impulses. Finding out why the client is behaving this way. Showing acceptance of the client. The primary initial focus of the nurse-client relationship is in showing the client, through acceptance, that it is the client one is concerned about, not the symptoms. Answers 1 and 2 are incorrect because the focus of initial nursing care is on the client, not on meeting hospital standards or controlling impulses. Answer 3 is incorrect because it is an attempt to analyze the whys of behavior, which is not an appropriate basic nursing intervention and not an initial aspect of care. The key word is "acceptance," a basic tenet of the nurse-patient relationship. The nurse is aware that the two major types of precipitating factors in anxiety are: Fear of disapproval and shame. Conflicts involving avoidance and pain. Threats to one's biological integrity and threats to one's self-system. A person's poor health and poor financial condition. This is the most inclusive answer. Answers 1, 2, and 4 are all incorporated into Answer 3. When all answers are correct, choose the "umbrella" answer that covers them all. After a patient with major depression visits with the spouse, the spouse reports that it was a stressful time. In an interview, the patient says, "We had a marvelous visit." The nurse is aware that this is an example of: Compensation. Denial. Symbolism. Identification. Denial is the act of avoiding disagreeable realities by ignoring them. Answer 1 is incorrect because compensation is the process by which a person makes up for a deficiency in self-image by emphasizing an asset. Answer 3, symbolism, is the use of one mental image to represent another. Answer 4, identification, is the process of taking on another person's attribute. Knowledge of coping mechanisms is necessary to select the only correct answer. Review definitions and examples of the most common coping mechanisms. Psychomotor manifestations of anxiety that a nurse may observe include: Decreased activity. Increased activity. Increased lability of emotions. Decreased lability of emotions. Research shows that increased activity is a psychomotor manifestation of anxiety; therefore, Answer 1 is wrong. Answers 3 and 4 are incorrect because emotion is not a psychomotor manifestation. Note the similarity between the word "psychomotor" in the stem and the word "activity" in Answers 1 and 2. Next decide on "increased activity" by applying theory about anxiety. A patient whose significant other recently died shows signs of grief resolution when he or she: Wants to enter into another relationship soon. Talks of both the positive and negative aspects of their relationship. Makes up for deficiencies in the relationship, saying, "Things would have been better if we had only had more time." Expresses anger toward the deceased. When the mourner can pass through the idealization stage and be more realistic about the positive and negative aspects of the loss, resolution of grief is beginning. Answers 3 and 4 occur in earlier stages of grief. Answer 1 could be a sign of denial of grieving, an initial grief reaction. Because all of the answers could be acceptable, you need to review the stages of grief to identify the best answer in relation to a time sequence. The other three options relate to earlier stages. The nurse needs to know that anxiety may increase intellectual functioning because anxiety may: Increase the perceptual field. Increase ability to concentrate. Decrease the perceptual field. Decrease random activity. Research shows that anxiety decreases the perceptual field; therefore, Answer 1 is incorrect. Research also shows that anxiety decreases the ability to concentrate and increases random activity; therefore, Answers 1,2, and 4 are incorrect. Note the two contradictory options: "increase perceptual field" vs. "decrease perceptual field." Next, apply knowledge about anxiety to select the theoretically correct answer. Answers 2 and 4 are theoretically incorrect. In planning patient care, a nurse needs to know that self-destructive behavior may be interpreted as the: Directing of hostile feelings toward self. Directing of hostile feelings toward others. Directing of hostile feelings toward an internalized love object. Internalization of the fear of death. This is correct by Freudian theory. Answers 1,2, and 4 are incorrect because they are incomplete. The correct answer directly stems from a particular theoretical viewpointFreudian, which you will need to review. Based on knowledge of Erikson's stages of growth and development, the nurse determines that the task of old age is primarily concerned with: Ego integrity versus despair. Autonomy versus shame and doubt. Trust versus mistrust. Industry versus inferiority. This is correct according to Erickson. Answer 2 relates to toddler; Answer 3, to infancy; Answer 4, to latency period in childhood. Review and apply your knowledge of the age-related stages, which will lead to the only correct answer. The nurse must assess for high risk of suicide when a patient's behavior suggests: Major depression with melancholia features. Schizophrenic disorders. Bipolar mood disorder, manic episode. Psychological factors affecting physical condition. Another name for major depression is depression with psychotic features. Suicide risk is a part of all depressions. Answers 2,3, and 4 are incorrect because these diagnoses alone do not indicate suicide risk as does the diagnosis of depression. Depression is the most common direct risk factor for suicide. In working with clients who are depressed, the nurse must know that depression may stem from: A sense of loss actual, imaginary, or impending. Revived memories of a painful childhood. A confused sexual identity. An unresolved oedipal conflict. Toss is most basic to the development of depression. Answers 2,3, and 4 are not essential to development of depression. When in doubt, choose the least controversial, more general answer ("a sense of loss") rather than pinpointing specific causal factors (e.g., "painful childhood," "confused sexual identity," "unresolved oedipal conflict"). When working with a person who is anxious, what is the overall goal of nursing intervention? Remove anxiety. Develop the person's awareness of anxiety. Protect the person from anxiety. Develop the person's capacity to tolerate mild anxiety and to use it constructively. Some anxiety is necessary to learn. Answer 2 is incorrect because it is incomplete. Answers 1 and 3 are incorrect because anxiety is necessary for learning and growth. When two answers seem right, choose the answer that incorporates the other (i.e., capacity to tolerate anxiety would also mean developing awareness of anxiety). In discussions between parents and adolescents about their relationship, a desired outcome is that adolescents benefit because they will be able to: See themselves as the victims. View their parents and themselves realistically. Enlist the therapist's aid as an ally against their parents. See their parents as victims. Part of maturing is learning to view one's parents and oneself realistically. Answers 1,3, and 4 are incorrect because they represent the misinformation that creates problems between individuals. The key word in the correct option is "realistically. The main nursing goal with clients with schizophrenic disorders is to: Set limits on their bizarre behavior. Establish a trusting, nonthreatening, reality-based relationship. Quickly establish a warm, close relationship to counteract their aloofness. Protect them from self-destructive impulses. A permissive atmosphere is the key, as well as a slowly evolving relationship (not quickly evolving, as in Answer 3) with room for distance. Self-destruction is not a persistent problem requiring major focus for concern, as in Answer 4. Answer 1 is not the best response because "acceptance" of bizarre behavior is more important than setting limits. Note the key words in the correct answer: "trusting, nonthreatening, reality-based relationship. A patient is placed in isolation for seclusion due to agitated behavior. The nurse knows it is essential that: Restraints be applied. All the furniture be removed from the isolation room. A staff member have frequent contacts with the patient. The patient be allowed to come out after 4 hours. Frequent contacts at times of stress are important, especially when a patient is isolated. The other choices are not useful because Answer 1, isolation, does not automatically imply the use of restraints; all furniture need not be removed (Answer 2), depending on the institution and the type of behavior exhibited by the patient; and there is no specific time limit (Answer 4), because time depends on individual behavior and the patient's individual needs. Eliminate the option with the global word "all." Next, eliminate the too-specific time frame ("4 hours") that is not based on the patient's behavior or safety. Then eliminate the option on restraints, which is a last-resort action. Now you can readily choose the simple, most obvious option about "frequent contacts. Which activity would be best for the nurse to suggest to a client who is depressed? Folding laundry or stapling paper sheets for charts. Playing checkers. Doing a crossword puzzle. Ice skating. An undemanding task that the client could finish would allow a feeling of successful accomplishment. Answers 2 and 3 require intellectual activity, which is usually slowed down during a depressive phase. Answer 4 requires a skill that the client may not have and that might frustrate the client to learn; also, the client may not have the psychomotor energy for ice skating. Apply the process of elimination. Eliminate the two activities that call for intact cognitive functioning (which is slowed down in depression). The best answer does not involve a great deal of physical exertion, either (Answer 4). A woman patient says to the nurse, "That patient over there is a lesbian." What is the best response by the nurse? Are you afraid she will attack you? That woman is not a lesbian. What did the woman do that makes you think she is a lesbian? Then stay away from her. The nurse should encourage the patient to explain her statement in order to understand the experience she is having. Answer 1 is incorrect because it offers an interpretation that may or may not be true. Answer 2 is incorrect because it denies the patient's perception without clarification. Answer 4 is incorrect because the nurse agrees with an unsupported statement. When none of the options is appropriate, sound out the responses, and choose the option closest to an attempt to seek clarification. Which activity could a nurse suggest that would be best for a client with hyperactive behavior? Solitary activity, such as reading. Hammering on metal in a jewelry-making class. Playing chess. Competitive games. It will provide energy release without the external stimuli and pressure of competitive games (Answers 3 and 4). Reading (Answer 1) usually requires sitting, which a client who is hyperactive cannot readily do. Apply theory about manic behavior (hyperactivity) and select the only option that helps the patient to externalize the energy (Answer 2), without additional stimuli (competitive games). A patient says to his mother, "You are controlling me." The mother asks the nurse what he may have meant. What is the best response by the nurse? He is upset and thinks you are taking charge of him. He resents always having to meet your expectations. I can't tell you. You will have to ask him. I think you can ask your son that. Do you want me to stay with you while you ask him? The mother needs to ask the patient, not the nurse, but the nurse should also support the mother and encourage her to interact with her son. Answers 1 and 2 are incorrect because they are interpretations that state opinions about the patient without his participation. Answer 3 is incorrect because no support is given to the mother. First, eliminate the two options that are interpretive (Answers 1 and 2); then choose the option that redirects the mother to the patient while providing support to the mother (Answer 4). When a client exhibits signs of amnesia, the nurse knows that this behavior is probably related to: Selectively forgetting and storing unacceptable thoughts, wishes, and impulses in the unconscious mind. Conscious, deliberate forgetting. Transferring to another situation an emotion felt in a previous situation where its expression would not have been acceptable. Unconscious imitating of the manners, behavior, and feelings of another. By definition, this is repression. Answer 2 is suppression; Answer 3 is displacement; and Answer 4 is identification. Review definitions of defense mechanisms in order to select the only correct answer. In caring for a patient at risk for suicide, the most important nursing action is to: Maintain constant awareness of the patient's whereabouts. Ignore the patient as long as he or she is talking about suicide, because a suicide attempt is unlikely. Relax vigilance when the patient seems to be recovering from depression. Administer medication. The patient must be constantly observed. Answer 2 is incorrect because all suicidal talk and gestures are to be taken seriously. If the patient talks about suicide, there may be an attempt. Answer 3 is incorrect because suicide risk is greater when depression is lifting, requiring greater vigilance. Answer 4 is incorrect because medication for depression may take up to 2 weeks to decrease symptoms, and the patient needs vigilant surveillance now. Key words; "most important nursing action." Eliminate the option that is a myth (Answer 2). Focus on the contradictory options: "constant awareness" vs. "ignore the patient" and "relax vigilance." Choose "constant awareness." Giving medications is not the most important nursing action. A client who attempted suicide recently remarked to the nurse the next morning, "Let's not think about that now. Maybe I'll feel like thinking about it later." The nurse identifies this as: Blocking. Denial. Suppression. Repression. By definition, this is the conscious, deliberate effort to avoid talking or thinking about painful, anxiety-producing experiences. Answers 1,2, and 4 are incorrect terms for the example given in the stem. Review definitions of coping mechanisms in order to select the correct answer. After a mastectomy, a woman says, "My husband won't love me anymore." What would be the most therapeutic response by the nurse? Of course your husband loves you. Tell me what has happened that makes you think your husband won't love you anymore. If you stop crying and fix yourself up, you will look good to your husband. Do you think your husband won't love you because you have lost a breast? This question attempts to get a specific description of what has happened and will allow the client to describe grief and feelings of low self-worth because of loss of a breast. Answer 1 is incorrect because it offers false reassurance. Answer 3 is incorrect because it is a stereotyped response to a woman and denies the client's actual loss. Answer 4 is incorrect because it is an interpretation that, although possibly true, the client may reject. Resolution of grief is better achieved if the client can state a connection. First, eliminate the options that give false reassurance (Answer 1), offer a stereotyped response (Answer 3), and are interpretive (Answer 4). Then, select the option that is an example of therapeutic communication, which helps the patient to elaborate and look for connections between feelings/belief and events. Repetitive hand washing is often seen when a client is experiencing guilt feelings. This ritualistic behavior can be described as a mechanism whereby the client attaches significance to the act of washing. The nurse would identify this behavior as: Symbolism. Fantasy. Isolation. Conversion. Symbolism is the most clearly descriptive mechanism. Answer 2, fantasy, is a mental activity; Answer 3, isolation, is the exclusion from awareness of a feeling; Answer 4, conversion, is a disruption of motor or sensory functioning. Review definitions of defense mechanisms to select the only correct answer. In conducting an assessment interview, the nurse needs to be aware that self-destructive behavior is determined by: A variety of factors, with the same factors present in each individual. Genetic disturbances. Interpersonal disturbances. A variety of factors, different for each individual. A variety of factors can cause self-destructive behavior, and these differ for each individual. Hence, Answers 2 and 3 are not the best choices because, although correct, they are examples of a variety of factors; Answer 1 is the opposite of the correct answer. Choose the most inclusive answer when two options are examples of a main point. Eliminate Answer 1, which is partially the same as Answer 4 but also the opposite ("same" vs. "different" factors). A client shouts at the nurse one morning, "Why do you waste your time on me? I'm not sick; I don't need you. Go talk to other patients. They are really sick!" The nurse identifies this as: Reaction formation. Denial. Intellectualization. Rationalization. Denial is the mind's way of protecting the self-system from a disturbing reality. Answer 1, reaction formation, is an expression of an attitude opposite to unconscious feelings; Answer 3, intellectualization, is giving rational reasons without expression of underlying feelings; Answer 4, rationalization, is the attempt to make one's behavior look like the result of logical thinking. Review defense mechanisms to select the only correct answer. Which term would the nurse use to describe the experience of an individual who thought he heard a machine gun when his neighbor's lawnmower backfired as she was mowing the lawn? Delusion. Hallucination. Identification. Illusion. This is correct by definition. Answer 1 is incorrect because delusion is a fixed idea arising out of a person's inner needs and contrary to observed facts. Answer 2 is incorrect because a hallucination is a misperception that is unrelated to an external stimulus. Answer 3 is incorrect because identification is the process of taking on another person's attribute. Apply knowledge about adaptive and maladaptive coping mechanisms. Notice the option that is different (i.e., not a coping mechanismAnswer 4). For an educated guess, ask yourself: "Which of the following is not like the others?" Then, select it (this helps to focus on patterns.) It would be important for the nurse to implement definite suicide precautions for a patient who is depressed if the patient's mood changed suddenly to one of: Cheerfulness. Psychomotor retardation. Agitation. Hostility. A person who has settled on a plan for suicide may become more cheerful. Answer 2 is incorrect because a person who is severely retarded in the psychomotor area cannot carry out a suicide act. Answers 3 and 4 are incorrect because the patient is more likely to be hostile and agitated if he or she does not have a suicide plan. Agitated behavior can also represent the need to "repent" for sins thought to be committed. Look at the two sets of contradictory options: "cheerfulness" (1) vs. "hostility" (4); "psychomotor retardation" (i.e., slowing down) (2) vs. "agitation" (3). Hostility and agitation can be paired and, therefore, ruled out; that leaves "cheerfulness" as the option that is different, and the one to select ("which of the following is not like the others?"). The nurse knows that the most characteristic task of puberty and adolescence, according to Erikson's stages of psychosexual development, is: Identity versus role confusion. Initiative versus guilt. Ego integrity versus despair. Intimacy versus isolation. This is the correct match between age period and developmental task. Answer 2 refers to preschool age, Answer 3 is characteristic of "maturity" in later years of life, and Answer 4 refers to young adulthood. Review age-related psychosocial growth and development stages according to Erikson. A patient recently attempted suicide by slashing the wrists. The crisis intervention nurse and physician agree that hospitalization is not necessary for this patient; therefore, the nurse needs to: Wish the patient luck and terminate the session. Make an appointment for tomorrow and give the patient a telephone number where the nurse can be reached tonight. Make an appointment for the patient in 2 weeks, when the wrists might be healed. Tell the patient to make an appointment when she or he wants to, at the local mental health clinic. On principle, the crisis intervention nurse needs to be immediately available to the patient. Answer 1 is incorrect because it abandons the patient. Answer 3 is incorrect because the patient needs to deal with the situation immediately. Answer 4 is incorrect because the patient might decide that the crisis intervention nurse is not interested in helping, and the patient needs immediate assistance. Continuity of care is the concept to apply in selecting the next step in time sequence. A 10-year-old boy was admitted to the hospital for a tonsillectomy. In the morning, the nurse notes that the bedding is wet. There are several boys his age in the room. Which initial approach would best demonstrate a nurse's understanding of enuresis and this patient's stage of growth and development? While proceeding to change the wet linens, ask him what sports he likes best, purposely ignoring the wet bed by staying on impersonal topics. Draw the curtains around his bed while changing the linen, saying, "I know that this must be embarrassing to you." Say nothing while changing the bed; return at another time, when the other boys are not in the room, and explain to him the medical-emotional reasons for enuresis. Sit down on the bed and convey acceptance of him as a person rather than focusing on the wet bed. The goal is to preserve ego strength through acceptance and respect of the patient as a person. Answer 1 focuses on the tangential and irrelevant; Answer 2 makes the problem more obvious to others in the room and makes an assumption without validation about how the patient must feel; Answer 3 is incorrect because it is usually not helpful to give a rational explanation for an emotional difficulty related to enuresis. Focus on the option with the key word "acceptance. A patient with an antisocial personality disorder arouses anxiety and frustration in the staff and tends to intimidate by manipulative behaviors. One morning the patient shouts at the nurse, "Since you won't give me a pass, go away, you fat pig, or I'll hit you." What is the most effective response by the nurse to a client who threatens or derogates? You are rude and I don't like it. It makes me not want to talk with you. That kind of talk will keep you here longer. What did I do wrong? I don't like to hear insults and threats. What is important about getting the pass today? The nurse must state feelings, without anger; show no intimidation; and then help the patient examine what he or she is doing and why. Answer 1 is incorrect because it points the finger in an angry, accusatory way and labels the patient in turn ("You are rude"). Answer 2 sounds like "Big Nurse" authoritarian and punitive. Answer 3 may place the nurse in a position to be intimidated and "kicked" by the patient. Sounding out the response may help eliminate the threatening-sounding answers (1,2) and the apologetic-sounding response (3). The better response to choose is one in which the nurse gives feedback and uses open-ended communication to seek clarification (4). In assessing the behavior of a child with autism, the nurse notes that a symptom that characteristically differentiates this child from one with Down syndrome is: Retardation of activity. Short attention span. Difficulty in responding to a nurturing relationship. Poor academic performance. Most children with Down syndrome are affectionate and enjoy being held and cuddled, whereas the opposite is usually the case with a child who is autistic. All other responses (1, 2, and 4) may apply to both Down syndrome and autism. Apply knowledge about characteristics of Down syndrome and autism to select an important difference related to interpersonal behavior. It is important for a nurse to understand that a patient's repetitive hand washing is probably an attempt to: Punish himself or herself for guilt feelings. Control unacceptable impulses or feelings. Do what the voices the patient hears tell him or her to do. Seek attention from the staff. A ritual, such as compulsive hand washing, is an attempt to allay anxiety caused by unconscious impulses that are frightening. Answer 1 is incorrect because it is the opposite of what the hand-washing ritual is intended to dothe ritual is aimed at absolving guilt, not punishing. Answer 3 is related to psychotic symptoms and not at all relevant to symptoms of ritualism. Answer 4 is incorrect because hand washing is aimed at relief of guilt and self-help to reduce anxiety, not at seeking attention from staff. Apply theory about psychodynamics underlying ritualistic behavior: getting a handle on and seeking relief from anxiety (rather than punishment). Eliminate the two other options because they do not relate to ritualism. In establishing a therapeutic nursing approach with a client who abuses and is dependent on substances, the nurse primarily needs to: Promote a permissive, accepting environment. Use a straightforward and confronting approach. Meet the client's need for a chemical substitute for the drug. Prevent the client's use of the addictive drug. It is important to provide external support in helping develop the superego. Answer 1 may promote manipulative behavior in the client. Answer 3 may foster additional dependence. Preventing the client's use of drugs (Answer 4) is not the primary step in building a nurse-client relationship based on therapeutic communication. Note the key word, "primarily"; then, focus on two contradictory options: permissive vs. confronting. Next, apply theory regarding addictive personalities and select "confronting" (Answer 2). At 2:30 a.m., a client walks out to the nurse's station complaining that he is choking, suffocating, weakening, and dying. He demands a cigarette. What is the best response by the nurse? Refuse and tell him it is against the rules. Call the doctor and inform the doctor of the client's request and behavior. Refuse and tell him the cigarettes are locked. Give him a cigarette and stay with him while he smokes. The client is anxious and needs someone with him. Answer 1 is incorrect because it ignores the client's anxiety and needs. Answer 2 is incorrect because it also ignores the client's anxiety, and uses the doctor as an excuse to ignore his needs. Answer 3 is incorrect because it also ignores the client's anxiety and needs, and gives a poor reason for refusal. First, recognize symptoms of anxiety; then, choose the only answer that appears to focus on the patient's anxiety (although you may not like this answer). What approach can the nurse use to best handle a client's disturbed behavior? Approve the behavior. Maintain consistency of approach. Encourage the client not to express negative opinions. Interpret for the client the reasons for the behavior. Consistency lets clients know consequences of behavior and develops trust. Answer 1 is incorrect because the nurse cannot approve all behavior (e.g., destructive behavior). Answer 3 is incorrect because it can be therapeutic to express negative opinions. Answer 4 is incorrect because interpretation of behavior is not always advisable. Clients may use interpretations of behavior to avoid consequences of behavior or may see them as an excuse not to change behavior. Look at the option with the key word, "consistency," as the better answer. Eliminate Answers 3 and 4 because they are examples of nontherapeutic approaches. The overall client goal in rape counseling is to help the victim: Forget the incident and repress her feelings in order to be able to carry on with her life. Identify the rapist in a court of law. Accept her part in the rape. Acknowledge, face, and resolve the reaction she is experiencing. The victim needs to engage in expression of the experience, which will assist her to work through her feelings so that the experience may not interfere in future interpersonal relations. To repress the incident, as in Answer 1, would make it continually interfere in her relationships. Answer 2 is done only after Answer 4 has been accomplished. Answer 3 is incorrect because the rape victim has no "part" in the rape. Focus on the key words in the stem: "overall client goal. Which is the most appropriate response to a client who states emphatically, "I hate them"? I will stay with you as long as you feel this way. Tell me about your hate. I understand how you can feel this way. For whom do you have these feelings? The nurse is asking the client to clarify and further discuss feelings. Answer 1 is incorrect because while staying with the client might convey acceptance, it does not help the client clarify or deal with feelings. Answer 3 is incorrect because it cuts off any further response from the client and because it is doubtful that the nurse can understand this person's feelings without clarification. Answer 4 is incorrect because it is more important to clarify the client's feelings than it is to understand the object of hate. Best answer is an attempt to clarify feelings, rather than to focus on facts ("For whom .."). The nurse observes for signs of heroin withdrawal, which may include: Rhinorrhea, sneezing, and high fever. Pupillary dilation, diaphoresis, and weight loss. Pupillary constriction, vomiting, and pruritus. Choreiform movements and frequent lip wetting. Note the eyes: when a person is on heroin, the pupils are constricted; during withdrawal, they are dilated. Withdrawal does not usually include high fever, pupillary constriction, or choreiform movements, as in Answers 1,3, and 4. Note two contradictory options about the eyes ("dilation" vs. "constriction"), and know which applies to withdrawal vs. being on heroin. The nurse will look for what likely outcome of methadone treatment for heroin abuse and dependence? Sedation. Euphoria. Neuritis. Blocking of the euphoric effect of heroin and elimination of craving. Methadone is a synthetic narcotic and has no euphoric effect. Methadone does not produce sedation (Answer 1), euphoria (Answer 2), or neuritis (Answer 3). Eliminate the three options that are not related to methadone. Review effects of methadone. An acutely agitated client becomes increasingly aggressive. The staff's verbal attempts to stop the aggressive behavior are not effective. The client begins to shout threats at the staff and other clients, throws furniture, breaks windows, and hits, kicks, and bites other clients and staff. The client has a prn order for medication when agitated. Which action should the nurse take initially? Orient the client to reality and place the client in a well-lit, quiet room. Give the ordered tranquilizer and put the client in bed with the side rails up. Lock the client in his or her room and call the doctor. Have at least two staff members physically restrain the client and take the client to a quiet room. With concern for danger to the other clients, staff, and the environment, it is essential for the client to be restrained at this time. The other choices are incorrect because orientation and a quiet environment alone do not provide for safety when the client's agitation is out of control (Answer 1); the initial delay in onset of effectiveness of the tranquilizer does not immediately provide for the safety needs of other clients, staff, and the environment (Answer 2); and locking the client in his or her room eliminates only the danger to othersadditional measures would be needed to provide for the safety of this client (Answer 3). Note the key word, "initially." Know when it is acceptable to use restraints. A teenage patient has a history of stealing cars and traffic violations. The home environment has been permissive, and the teenager has been overly familiar and obsequious with the nurses. A new nurse, about to leave the locked unit, is holding the key as the patient approaches and eagerly offers to unlock the door for the nurse, saying, "The other nurses let me." Which first response by the nurse would be most appropriate? Let the patient turn the key in the lock, but stay close while the patient does it. Ask the patient why he or she wants to unlock the door. Tell the patient in a nice way that this is not allowed. Go to the head nurse and ask if it is all right for the patient to unlock the door. Based on the patient's history of antisocial behavior, he or she is probably attempting to use the nurse for his or her own purpose and is not truthful. Therefore, it is best that the new nurse on the unit go directly to the head nurse to check on what is permissible and not accept the patient's word that it is permissible. Answer 1 is not helpful because allowing the patient to unlock the door may feed into the manipulative attempt by the patient to get off the unit. Answer 2 is incorrect because asking a "why" question is not a therapeutic communication. Answer 3 is incorrect because this option places the new nurse in an argumentative position with the patient, who is likely to become defensive and say, "Oh, yes. I am allowed to open doors." Note the key word: "new" nurse. Review the theory about acting-out and manipulative behavior. Select the answer that calls for consistency among staff (4). Several staff members voice their frustrations about a patient's constant questions, such as "Should I go to the day-room or should I stay in my room?" and "Should I have a cup of tea or a cup of coffee?" Which interpretation about this behavior will help the nursing staff deal effectively? The patient's inability to make decisions reflects a basic anxiety about making a mistake and being a failure. The patient's indecisiveness is aimed at testing the staff's reaction and acceptance of him or her. The patient's dependence on others (staff) is a symptom that needs to be interrupted by firm limit setting. The patient's need to ask questions is a bid for attention. Limit setting is an important intervention with a patient who exhibits excessive, constant dependence on others for simple, seemingly inconsequential decisions in everyday life. The other choices are wrong because the situation presented provides insufficient data on which to base interpretations related to fear of failure (Answer 1), a need to test for staff acceptance (Answer 2), or a bid for attention (Answer 4). Eliminate the three options for which there are no data in the stem to validate the interpretations (Answers 1,2, and 4). In providing dietary instructions to an Orthodox Jewish client who is depressed, the nurse needs to know that which practice would be prohibited in dietary Kosher laws? Eating dairy products with meat. Eating meat from animals with cloven hoofs. Eating fish with scales and fins. Eating unleavened bread during the 8 days of Passover. This is the only correct answer regarding dietary prohibitions. Answers 2,3, and 4 are allowed. Knowledge regarding Orthodox Jewish dietary laws is needed to select the correct option. Note the key word: "prohibited" (i.e., not not allowed). A patient with antisocial behavior flatters the nurse. What is the patient trying to do? The patient wants something in return The patient wants the nurse to like him. The patient needs attention. The patient is trying to redirect the focus of the nurse-patient interaction. Manipulation is a characteristic antisocial behavior. Flattery is a form of manipulationwith hidden agenda, to get what the patient wants, whatever that may be. Answer 2 may or may not be the agenda behind the flattery. Answers 3 and 4 are also possible examples of what the patient wants. When more than one answer is plausible, choose the one that covers them allthe "umbrella" answer (1). A patient with schizophrenia is banging on the hallway door leading to the outside, saying he needs to go to an appointment. What nursing intervention is needed? Ask the patient to move away from the door. Ignore this behavior. Escort the patient back into the room. Tell the patient that he cannot bang on the door. Gentle but firm guidance and nonverbal direction is needed to intervene when a patient with schizophrenic symptoms is being disruptive. Answer 1 requires the patient to listen and respond accordingly. This behavior is disruptive and should not be ignored (Answer 2). Answer 4 says only what cannot be done, without providing an alternative activity. Knowing the theory about characteristics of schizophrenia (e.g., autistic behavior, thought disorders) would help eliminate Answers 1 and 4. Ignoring disruptive behavior is not appropriate. The process of elimination leads to Answer 3 as the best answer. In preparing a patient for ECT, the nurse knows that succinylcholine (Anectine) will be administered for which therapeutic effect? Skeletal muscle paralysis. Short-acting anesthesia. Decreased oral and respiratory secretions. Analgesia. is correct because it is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures or dislocation. Answer 2 is incorrect because it describes the action of methohexital (Brevital), which is administered in the treatment room before ECT. Answer 3 is incorrect because it describes the action of atropine sulfate, given IM 30 minutes before treatment, to decrease secretions and counteract vagal stimulation effects induced by ECT. Answer 4 is incorrect because analgesia is not required in ECT (before, during, or after), and it is not related to Anectine. Knowledge of the three standard drugs used in ECT and their effects will lead to the best answer. The nurse can anticipate that the person most likely to be at risk for depression is: An elderly person with previous depressive episodes. A middle-aged man who is a moderate alcohol drinker. A housewife with three school-age children. A nursing student at exam time. is correct because depressive episodes are often recurrent. Answers 2,3, and 4 may or may not experience depression. Answers 2 and 4 are more likely to experience anxiety. There does not appear to be any reason to expect that a housewife with three children in school would be at risk for any particular emotional distress (Answer 3). Match the key word in the answers, "depressive," with the key word in the stem, "depression. In admitting a patient with Alzheimer's to the unit, which placement variable would have the highest priority: Place the patient with a roommate. Place the patient without a roommate. Place the patient close to the nurses' station. Place the patient at a distance from the nurses' station. Nursing observation is easier if the patient with Alzheimer's is nearby. Therefore, Answer 4 is incorrect. A roommate may (Answer 1) or may not (Answer 2) be all right, but facilitating nursing observations is the highest priority for a patient with memory problems and confusion who is a safety risk for wandering off the unit. Focus in on the best option by first narrowing choices to two that are contradictory (with/without a roommate; near/at distance from the nurses' station). Then ask, Is it roommate or proximity to nurses' station that is the priority? Next, consider what goal is met by being near the nurses' station rather than a roommate. Answer: safety from wandering. During a home health assessment visit to an elderly patient living alone, which aspect of lifestyle noted by the nurse would be of greatest concern? The family visits only twice a month. The family maintains only phone contact daily. The patient uses a cordless telephone rather than a standard phone. The patient prefers not to attend a senior citizen center for meals and recreation. This is the correct answer because it lets the nurse know that contacts with the elderly person are infrequent and that ongoing assessment of needs and health concerns is not likely to occur. Answer 2 is incorrect because it is not the greatest concern, as long as there is the opportunity for assessment by phone. A cordless phone is a good idea rather than a great concern (Answer 3). Although isolation is further increased by not wanting to go to a senior citizen center, it is not of greatest concern (Answer 4). Put logic and reasoning to work here. Look at patterns in the stem: two options focus on family (1, 2), one option focuses on a phone instrument (3), and another option focuses on a community agency (4). A hospitalized patient with Alzheimer's disease is often found wandering in the streets. What measure(s) should be taken in the unit to prevent the patient from wandering off? Place the patient in daytime restraints. Place the patient in nighttime restraints. Provide a security guard at the door. Use electronic surveillance devices. This answer is concerned with accident prevention and is a means of observation of the patient. Answers 1 and 2 are incorrect because the use of restraints is inappropriate and not justified. Having a security guard is not realistic (Answer 3). Use the process of elimination. Eliminate the two options dealing with restraints; eliminate the most unlikely option (Answer 3); Answer 4, therefore, is the best answer. What parental behavior toward a child during admission procedure should cause the nurse to suspect child abuse? Acting overly solicitous toward the child. Ignoring the child. Expressions of guilt. Flat affect. This is an example of reaction formation, a coping mechanism. Answer 2 is incorrect because "ignoring" is the opposite of Answer 1, the correct choice. Answer 3 is incorrect because guilt may be manifested by being overly solicitous (Answer 1). Answer 4 is incorrect because "flat" is the opposite of an emotional reaction/action (overly solicitous). Remember Shakespeare: "Methinks the (lady) doth protest too much"showing care and concern (love) but inflicting harm (hate). Which nursing action would be best for a hospitalized patient who is constantly upset with the staff, easily angers, and frequently shouts at the nurses? Request that the patient be moved to another unit. Schedule a conference with the MD, nurse manager, and patient about this behavior. Contact social services to meet with the patient and family about the problem. Involve the patient and family in the development of the care plan. The patient is probably experiencing a loss of control over the hospitalization situation. Initially the patient and family should be included in planning care, which returns decision making to the patient and decreases frustration. Answers 1 and 3 shift the problem rather than attempt to resolve the issue. Answer 2 involves the patient but brings in an authority figure (the MD), which may be seen as punish ment or "parental" by the patient. Look for the choice that gives the patient the most control; do not "pass the buck" to someone else (MD, social services, etc.) Which nursing action would be most appropriate for a nursing diagnosis of "self-esteem disturbance"? Compliment the patient as often as possible. Assist the patient to set reasonable, achievable goals. Assure the patient that all needs will be met. Encourage the patient's family to praise the patient verbally. The patient needs to experience personal success. Setting reasonable and achievable goals will affirm the patient's value and ability to succeed. Answers 1,3, and 4 will most likely be meaningless to a patient who does not feel important or successful. The choices are all verbal with no active participation by the patient. Maximize the patient's actions. Choose an option that "assists" the patient to do something. During a group education session on recovering from a myocardial infarction, one patient blurts out, "I don't agree with what you are saying." The best response would be: Tell us where your information came from. I'll talk to you after the class is over. I've had patients say that before, but they were wrong. Give us an example of what you feel is incorrect. It is important to recognize differences of opinion and clarify patient perceptions of information presented without appearing defensive or putting the patient on the defensive. The patient may be anxious following an MI, and the out burst may be an indication of fear and anxiety. Answers 1,2, and 3 are defensive or avoiding responses by the nurse. Only one option acknowledges the patient's statement as important to address.