Nokea
Which of the following historical data is the greatest risk factor for hypochondriasis?
- A. The client experienced parental neglect as a child.
- B. The client has a sibling with schizophrenia.
- C. The client experienced parental overprotection as a child.
- D. The client has a history of substance abuse.
Correct Answer: C
Rationale: Parental overprotection can foster excessive health concerns, contributing to hypochondriasis by reinforcing anxiety about physical symptoms.
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The nurse is to administer haloperidol 2 mg IV now to the hospitalized client. A vial of haloperidol 5 mg/mL is available. How many milliliters of medication should the nurse administer?____________ mL (Record your answer rounded to the nearest tenth.)
Correct Answer: 0.4
Rationale: Using proportion: 5 mg/1 mL = 2 mg/X mL; 5X = 2; X = 0.4 mL.
Multiple clients are being cared for on the behavioral health unit. In which circumstances should the nurse plan the therapeutic use of seclusion and/or restraints? Select all that apply.
- A. The client asks to be placed in seclusion.
- B. The client expresses the likelihood of self-injury.
- C. The staff feels the client is likely to harm others.
- D. A legally detained client is threatening to “escape.”
- E. The staff identifies seclusion as a consequence of the client’s behavior.
- F. The client’s threatening behavior is negatively affecting the therapeutic milieu.
Correct Answer: A, B ,C, D
Rationale: Seclusion/restraints are therapeutic for client request (A) self-injury risk (B) harm to others (C) or escape threats (D). Punishment (E) or milieu disruption (F) alone are not indications.
When interacting with a client experiencing a panic attack, which technique by the nurse is most likely to help reduce the client's anxiety level?
- A. Stand less than an arm's length away.
- B. State that everything is going to be okay.
- C. Instruct the client to take shallow breaths.
- D. Explain all actions and procedures.
Correct Answer: D
Rationale: Explaining actions provides predictability, reducing anxiety by enhancing the client's sense of control during a panic attack.
Staff members have expressed fear of the client who has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff’s expressed concerns?
- A. “Let’s not prejudge him. His medication should help him control his behavior.”
- B. “I will be very attentive to his behavior monitoring it for any signs of escalation.”
- C. “It may be hard but we need to appear calm and nonthreatening but alert to his behavior.”
- D. “As staff we are all trained to manage violent clients and we can handle any crisis behavior.”
Correct Answer: C
Rationale: Appearing calm and nonthreatening (C) addresses staff concerns and guides management. Prejudging (A) personal monitoring (B) or overconfidence (D) dismiss staff fears.
If the client is typical of others of similar age, the nurse can anticipate the client as having which age-related problems? Select all that apply.
- A. Becoming cynical
- B. Losing patience
- C. Developing hostility
- D. Having periods of regret
- E. Experiencing episodes of depression
Correct Answer: D,E
Rationale: Regret and depression are common in late adulthood as individuals reflect on life, per Erikson's integrity vs. despair stage.