Question

A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

Answer 1

Correct Answers:

Whether the client is a danger to herself or others.

Rationale :

✨ Involuntary admission is legally justified only when a client poses a risk to self or others.

✨ The primary goal of holding a client beyond the initial period is to ensure safety and prevent harm.

✨ Mental health laws prioritize protection over voluntary consent when a client exhibits violent or harmful behavior.

✨ The 72-hour hold can be extended only after mental health professionals determine continued danger exists.

✨ This ensures ethical and legal compliance with mental health policies to protect both the client and the public.

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Answer 2

Correct Answers:

"I have heard that abusers think of themselves as important and have high self-esteem."

Rationale :

🔹 Abusers typically have low self-esteem, which contributes to controlling behaviors.

🔹 Many project power and dominance to compensate for feelings of insecurity.

🔹 The belief that abusers have high self-esteem is a misconception, indicating a need for further teaching.

🔹 Risk factors include poor social skills, jealousy, and need for control, not genuine confidence.

🔹 Understanding true psychological patterns is crucial for early detection and intervention in domestic violence.

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Answer 3

Correct Answers:

Denial

Rationale :

⚫ Denial is a defense mechanism where the client refuses to accept reality to reduce anxiety.

⚫ The client’s calm statement, “I’m fine,” despite traumatic injuries, indicates an avoidance of emotional distress.

⚫ This is common in trauma survivors who may suppress reactions as a temporary coping method.

⚫ Recognizing denial helps nurses provide therapeutic support rather than confronting the client abruptly.

⚫ Early identification allows for gradual emotional processing and trust-building in care.

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Answer 4

Correct Answers:

"I call a friend who makes me smile and laugh."
"I think about being on my favorite beach vacation."
"I tense and release my muscles, starting with my feet."

Rationale :

"I call a friend who makes me smile and laugh."

🟢 Social support is a positive coping mechanism that enhances emotional resilience.

🟢 Talking to trusted people reduces stress hormone levels and improves mental health.

🟢 Maintaining connections prevents isolation-related depression during stressful periods.

"I think about being on my favorite beach vacation."

🟢 Visualization is an adaptive strategy that triggers relaxation by stimulating positive emotions.

🟢 This technique shifts focus from stressful stimuli to calming, pleasant memories.

🟢 It is frequently used in stress management therapy to lower anxiety levels.

"I tense and release my muscles, starting with my feet."

🟢 Progressive muscle relaxation decreases muscle tension caused by stress.

🟢 It activates the parasympathetic nervous system, promoting physical calmness.

🟢 Nurses often teach this method to reduce acute anxiety symptoms effectively.

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Answer 5

Correct Answers:

The client learns to change negative thoughts into positive statements.

Rationale :

🔵 Cognitive reframing involves replacing irrational, negative thoughts with realistic positive ones.

🔵 This improves emotional response by changing perception of stressful situations.

🔵 It is based on cognitive-behavioral therapy (CBT) principles for mental health management.

🔵 Clients learn to identify automatic negative thoughts and substitute them with supportive affirmations.

🔵 Over time, this promotes long-term adaptive thinking patterns and reduces stress.

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Answer 6

Correct Answers:

Stay with the client during meals and for 1 hr afterward.
Monitor the client's weight daily after first voiding.
Offer specific privileges for sustained weight gain.

Rationale :

Stay with the client during meals and for 1 hr afterward.

🟠 Supervised eating prevents purging behaviors such as vomiting or laxative use.

🟠 Continuous observation supports healthy eating patterns and builds trust.

🟠 This is an essential safety measure in anorexia nervosa treatment.

Monitor the client's weight daily after first voiding.

🟠 Daily weights at the same time ensure accurate fluid and weight monitoring.

🟠 Weighing after first morning voiding reduces variation caused by fluid retention.

🟠 Tracking weight trends helps evaluate treatment effectiveness and guides care plans.

Offer specific privileges for sustained weight gain.

🟠 Positive reinforcement encourages compliance with nutritional plans.

🟠 Rewards help increase motivation, especially in clients with poor insight into illness.

🟠 This method supports behavioral modification and gradual recovery.

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Answer 7

Correct Answers:

Depression
Anxiety
Obsessive-compulsive disorder

Rationale :

Depression

🔷 Depression is a common comorbidity in eating disorders due to low self-esteem and distorted body image.

🔷 Clients often experience hopelessness and feelings of worthlessness, which worsen restrictive eating behaviors.

🔷 Chronic malnutrition can lead to changes in neurotransmitter levels (e.g., serotonin), increasing depressive symptoms.

🔷 Depression also increases the risk for suicidal ideation, making early recognition critical in treatment.

🔷 Addressing depression alongside the eating disorder improves psychological recovery and adherence to therapy.

Anxiety

🔷 Anxiety frequently coexists with eating disorders, manifesting as excessive worry about food, weight, or appearance.

🔷 Many clients experience anticipatory anxiety before meals, which can trigger avoidance or purging behaviors.

🔷 High anxiety levels are linked to perfectionism traits, a strong predictor of disordered eating patterns.

🔷 Treating anxiety helps reduce ritualistic behaviors and promotes healthier coping mechanisms.

🔷 Anxiolytic therapy and CBT are often integrated to improve treatment outcomes.

Obsessive-compulsive disorder (OCD)

🔷 OCD behaviors are common in eating disorders, including ritualistic food preparation, calorie counting, and rigid exercise routines.

🔷 These compulsions are driven by an overwhelming need for control and perfectionism.

🔷 OCD symptoms reinforce disordered eating cycles, making nutritional rehabilitation challenging.

🔷 Identifying OCD comorbidity guides behavioral modification strategies to break compulsive patterns.

🔷 SSRIs and behavioral therapy are often used to manage OCD in clients with eating disorders.

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Answer 8

Correct Answers:

"Tell me what makes you feel the client is doing this on purpose?"

Rationale :

♦ Therapeutic communication encourages expression of feelings without judgment.

♦ Asking this open-ended question helps the AP explore underlying frustration.

♦ It promotes self-awareness and prevents staff from developing negative attitudes.

♦ The nurse guides the AP toward understanding the medical causes of incontinence.

♦ This fosters empathy and improves quality of care for the client.

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Answer 9

Correct Answers:

Remain with the client.

Rationale :

🔴 Staying with the client provides immediate emotional support and safety during acute anxiety.

🔴 Physical presence helps reduce feelings of isolation and fear.

🔴 It allows the nurse to monitor for signs of panic or escalating distress.

🔴 Establishing a calm, reassuring environment is the first priority before other interventions.

🔴 Trust-building through presence helps stabilize the client for further therapeutic steps.

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Answer 10

Correct Answers:

Low bone density.

Rationale :

🟣 Osteopenia or osteoporosis is common due to chronic malnutrition and low estrogen.

🟣 Amenorrhea in anorexia nervosa leads to decreased bone mineralization.

🟣 Long-term calcium and vitamin D deficiency worsen skeletal fragility.

🟣 Early detection prevents fractures and irreversible bone damage.

🟣 Bone health assessment is a critical part of anorexia management.

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PNU Adult Health II spring 2023 Exam 2

No.

1 :
A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

2 :
A nurse in a community clinic is speaking to other nurses about risk factors for domestic violence. Which of the following statements by one of the other nurses indicates the need for further teaching?

3 :
A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

4 :
A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicates adaptive coping? (Select all that apply.)

5 :
A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

6 :
A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)

7 :
A nurse is discussing comorbidities associated with eating disorders with a newly licensed nurse .Which of the following comorbidities should the nurse include in the discussion? (Select all that apply.)

8 :
An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

9 :
A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

10 :
A nurse is collecting data from a female client who has anorexia nervosa. Which of the following findings should the nurse expect?

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PNU Adult Health II spring 2023 Exam 2

No.

1 : A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

2 : A nurse in a community clinic is speaking to other nurses about risk factors for domestic violence. Which of the following statements by one of the other nurses indicates the need for further teaching?

3 : A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

4 : A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicates adaptive coping? (Select all that apply.)

5 : A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

6 : A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)

7 : A nurse is discussing comorbidities associated with eating disorders with a newly licensed nurse .Which of the following comorbidities should the nurse include in the discussion? (Select all that apply.)

8 : An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

9 : A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

10 : A nurse is collecting data from a female client who has anorexia nervosa. Which of the following findings should the nurse expect?

1 :
A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

2 :
A nurse in a community clinic is speaking to other nurses about risk factors for domestic violence. Which of the following statements by one of the other nurses indicates the need for further teaching?

3 :
A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

4 :
A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicates adaptive coping? (Select all that apply.)

5 :
A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

6 :
A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)

7 :
A nurse is discussing comorbidities associated with eating disorders with a newly licensed nurse .Which of the following comorbidities should the nurse include in the discussion? (Select all that apply.)

8 :
An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

9 :
A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

10 :
A nurse is collecting data from a female client who has anorexia nervosa. Which of the following findings should the nurse expect?