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The nurse should plan which goals of the termination stage of group development? Select all that apply. - correct answer - the group evaluates the experien... [Show More] ce. - The group explores members' feelings about the group and the impending separation. A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? - correct answer "You're feeling angry that your family continues to hope for you to be cured?" When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? - correct answer Monitor closely for harm to self or others. The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. - correct answer -Restating - Listening - Maintaining neutral responses - Providing acknowledgment and feedback A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach? - correct answer Milieu therapy The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? - correct answer Inquiring about and examining the client's feelings for any that may block adaptive coping A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? - correct answer Use an indirect light source and turn off the television. The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? - correct answer Setting limits on the client's behavior A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult? - correct answer Conversion disorder Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. - correct answer - Communicate expected behaviors to the client. - Assist the client in identifying ways of setting limits on personal behaviors. - Follow through about the consequences of behavior in a nonpunitive manner. - Have the client state the consequences for behaving in ways that are viewed as unacceptable. The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? - correct answer "When I have command hallucinations, I'll call a friend and ask him what I should do." The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriatenursing intervention? - correct answer Sit beside the client in silence with occasional open-ended questions. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? - correct answer Writing Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. - correct answer - Monitor vital signs. - Provide a safe environment. -Address hallucinations therapeutically. - Provide reality orientation as appropriate. A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? - correct answer Call the nursing supervisor. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. - correct answer - Loss of tooth enamel -Electrolyte imbalances - Dental decay A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? - correct answer A client undergoing diagnostic tests rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? - correct answer Hypertension, changes in level of consciousness, hallucinations alcohol withdrawal delirium symptoms - correct answer delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions. The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? - correct answer "What do you find difficult about this situation?" A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? - correct answer Evidence of the client's disturbed body image The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? - correct answer The death of a loved one situational crisis - correct answer arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. adventitious crisis - correct answer a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse). adventitious crisis - correct answer - Witnessing a murder - A fire that destroyed the client's home - A recent rape episode experienced by the client The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. - correct answer - Acknowledge the client's behavior. - Assist the client to an area that is quiet. - Maintain a safe distance from the client. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? - correct answer Increasing the level of suicide precautions A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? - correct answer "Tell me more about the incident that causes you to feel like the rape just occurred." A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. - correct answer - I keep reliving the robbery." - "I see his face everywhere I go." - "I might have died over a few dollars in my pocket." The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? - correct answer Removing the client from any immediate danger The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? - correct answer Nonstop physical activity and poor nutritional intake The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? - correct answer Use of confabulation confabulation - correct answer the act of filling in memory gaps by making up stories The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? - correct answer Observing rigid rules and regulations A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? - correct answer Identify recent behaviors or accomplishments that demonstrate the client's skills. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? - correct answer An expected coping mechanism A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? - correct answer "This form of therapy provides a negative reinforcement when the stimulus is produced." The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? - correct answer Provide authority, action, and participation. A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? - correct answer Remain with the client until the anxiety decreases. The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? - correct answer Lack of ability to cope effectively Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide? - correct answer "Discussing suicide with a client is not harmful." Which client is at greatest risk for committing suicide? - correct answer A client with metastatic cancer Which statement by the nurse indicates a need for further teaching concerning family violence? - correct answer "Abusers are more often from low-income families." Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client? - correct answer Assure that an electrocardiogram is performed within 24 hours. A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy? - correct answer "It uses negative reinforcement." The nurse in the mental health unit is performing an assessment in a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? - correct answer Somatization disorder Somatization disorder - correct answer is characterized by a long history of multiple physical problems with no satisfactory organic explanation. Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. A psychological issue that causes to report physical symptoms such as pain The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to go straight." Which response by the nurse would be therapeutic? - correct answer "Tell me what makes you feel that you are ready. A client diagnosed with depression shares with the outclinic nurse, "I lost my job this week and can't pay my rent. My daughter is my only family, but I don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern? - correct answer "Wouldn't you want to know if your daughter was having difficulties so you could help if you could?" During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries? - correct answer "The focus of today's session is on your issues, so let's get started." The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client? - correct answer "You're wearing a new blouse." Which activity should the nurse include in the plan of care for a client who is experiencing psychomotor agitation? - correct answer Attending a clay-molding class that is scheduled for today Psychomotor agitation - correct answer is a symptom related to a wide range of mood disorders. People with this condition engage in movements that serve no purpose. Examples include pacing around the room, tapping your toes, or rapid talking. Psychomotor agitation often occurs with mania or anxiety. The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply - correct answer - Assist the client in selecting foods from the food menu. - Offer high-calorie fluids throughout the day and evening. - Offer small high-calorie, high-protein snacks during the day and evening. incongruent - correct answer is not the same, not compatible or out of place. inappropriate affect - correct answer refers to an emotional response to a situation that is incongruent with the tone of the situation. The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? - correct answer The client giggled while describing being physically abused as a child. A flat affect is manifested as an immobile facial expression or blank look - correct answer A flat affect is manifested as an immobile facial expression or blank look The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? - correct answer During the entire family visit, the client presented with an expressionless, blank look. The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply. - correct answer - Ask permission before touching the client. - Eliminate all unnecessary physical contact with the client. - Defuse any anger or verbal attacks with a nondefensive stance. - Use simple and clear language when communicating with the client. The nurse is preparing a client for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. - correct answer - Have the client void. - Obtain an informed consent. - Remove dentures and contact lenses. - Withhold food and fluids for 6 hours. A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? - correct answer - White blood cell count Before giving the client the initial dose of disulfiram, what should the psychiatric home health nurse determine? - correct answer When the last alcoholic drink was consumed The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? - correct answer Dementia The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis? - correct answer "I'd be sure to have a panic attack if I left my house." Agoraphobia - correct answer a fear of leaving the house and experiencing panic attacks when doing so. A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom? - correct answer Encourage frequent fluid intake and a high-fiber diet. A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement describes the nurse's obligation to the client? - correct answer Share that the risk to their safety requires that the client's HCP be notified. Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? - correct answer The client's noncompliance with medication therapy During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primarycharacteristics of bulimia? - correct answer Eating a lot of food in a short period of time and misuse of laxatives What is the appropriate nursing intervention for a client diagnosed with posttraumatic stress disorder and paranoid tendencies who begins to pace and fidget? - correct answer Share the observation with the client so the behavior can be recognized. During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with posttraumatic stress disorder? - correct answer Making the client feel safe A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame? - correct answer 1 week after the 3rd treatment session The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed? - correct answer Disulfiram Which information provided by the nurse accurately describes electroconvulsive therapy? Select all that apply. - correct answer - The average series involves 8 to 12 treatments. - Some confusion may be noted after the procedure. - Memory loss will occur but will resolve with time The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar? - correct answer Progressive muscle relaxation techniques are useful for easing tension from many causes. A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met Bobby. My mother beats me every day, and my dad has sexually abused me since I was 10 years old!" Which response is appropriate for the nurse to make? - correct answer "It seems that you needed Bobby's help to separate from your family During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response? - correct answer "Have you shared your concerns with the police?" The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle? - correct answer The group should be limited to no more than 10 members. Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. - correct answer - Panic disorder - Posttraumatic stress disorder - Obsessive-compulsive disorder The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? - correct answer "My rituals are ways for me to control unpleasant thoughts or feelings." The nurse is preparing to create a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse should plan to include which component as a priority in the plan of care? - correct answer Individualized goals and objectives A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis? - correct answer Somatization disorder The nurse is planning to instruct a mental health client and the family about the importance of medication compliance. The nurse should plan for which interventions that are associated with increased compliance? Select all that apply. - correct answer - Including the family in the medication planning process - Working with the psychiatrist to find the right medication at the right dose - Providing the client with the injectable, long-acting form of the medication if available - Working with the psychiatrist to find the medication that provides the least side effects for the client Which statement by the client best reflects the development of an effective coping response style and effective processing of information for a hospitalized client participating in Alcoholic Anonymous (AA)? - correct answer "I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you people." The psychiatric home care nurse visits a client diagnosed with a phobia that triggers panic attacks. When teaching the client to use paradoxical intention, which intervention will the nurse demonstrate? - correct answer Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor The nurse is reviewing the medical record of a hospitalized client who received electroconvulsive therapy (ECT) 3 years ago. Which assessment data would support that the therapy resulted in retrograde amnesia in the client? - correct answer During the admission interview, the client can't remember why the ECT treatment was originally prescribed. Retrograde amnesia - correct answer difficulty recalling information learned before ECT. This kind of amnesia may be long-term The mother of a teenage client states that her daughter, diagnosed with an anxiety disorder, "eats nothing but junk food, has never liked going to school, and hangs out with the wrong crowd." What discharge instruction will be most effective in helping the mother to manage her daughter's condition? - correct answer Restrict the amount of chocolate and caffeine products in the home. The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which medical diagnosis, if noted on the client's record, would indicate a need to contact the health care provider scheduled to perform the ECT? - correct answer Recent myocardial infarction The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for acute depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment? - correct answer "I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end." The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency? - correct answer When asked to pick up the cup, the client consistently fails to identify the cup. agnosia - correct answer the inability to identify well-known objects and people. A client admitted to the mental health unit after attacking his father for disturbing him at his computer, interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my computer project to save the world!" Which nursing response will have the greatest therapeutic impact? - correct answer "I will be back to talk with you in 15 minutes after I complete nursing rounds." The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the besttherapeutic value? - correct answer "Do you recall what it was like before you started your medication?" Which client's death was achieved by what is considered a soft suicide method? - correct answer Sat in a running car parked in her locked garage to die of the carbon monoxide inhalation soft suicide methods - correct answer those that are painless and include ingesting pills, or inhaling natural gas or carbon monoxide. Hard suicide methods - correct answer include using a gun, jumping off a high place such as a bridge, hanging, and staging a car crash. A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement supports the existence of an alcohol tolerance problem? - correct answer "I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep. The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client? - correct answer Provide a structured daily program of activities, and encourage the client to participate. The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? - correct answer Fist clenched, pounding table, fearful A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion? - correct answer Gathering subjective and objective assessment from the caregiver and the client Which is a primary behavior of a client diagnosed with antisocial personality disorder? - correct answer Will take personal items from other clients' rooms The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation? - correct answer Making decisions about living arrangements after discharge dependent personality - correct answer is the inability to make decisions with excessive dependence on others. The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms? - correct answer Signs may appear at any time. Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication? - correct answer Wernicke-Korsakoff syndrome A supervisor reprimands the charge nurse for not adhering to the unit budget. What behavior by the charge nurse is an example of displacement? - correct answer The charge nurse blames staff for wasting supplies. Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initialnursing action? - correct answer Remain with the client until the anxiety decreases. Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety? - correct answer Is pacing while describing the situation using a rapid speech pattern A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on? - correct answer The client's physical condition A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective? - correct answer My friends and I went out to lunch today." A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior? - correct answer The client will employ new coping methods that will resolve the problem. Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning? - correct answer "My boss tells me that I'm being considered for a promotion and a raise." A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action? - correct answer Providing the clients with shelter, clothing, and food Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply. - correct answer - Verbal communication is almost nonexistent. - The client needs frequent redirection because of short attention span. The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking? - correct answer Present verbal instructions regarding expectations in single, simple commands. Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? - correct answer The client is convinced that the curtains are actually ghosts. During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likelythe result of which client factor? - correct answer Impaired pain perception A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initialintervention? - correct answer Turn off the television. The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primaryintervention? - correct answer Including the client's support system in the teaching The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking two packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury? - correct answer Diminishing the effectiveness of psychotropic medication Which goal addresses the therapeutic management needs of a client experiencing hallucinations? - correct answer Facilitate the client's awareness that the hallucination is not the reality of the world. The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply. - correct answer - A birthday of March 30 - A loss of interest in hobbies - A suicide attempt 6 months ago - Magnetic resonance imaging shows temporal lobe atrophy The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia? - correct answer Atrophy of the lateral and/or third ventricles of the brain The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? - correct answer Coffee, tea, and soda consumption should be limited. Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply. - correct answer - Is related to abnormal melatonin metabolism - Improves during the spring and summer months - Is a result of alterations in the available amounts of sunlight - A craving for carbohydrates lessens during sunnier and spring months Which are the most likely characteristics of a client who abuses alcohol? Select all that apply. - correct answer - Male gender - Abuses drugs as well as alcohol - History of at least one suicide attempt The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction? - correct answer Impaired wound healing An adolescent has been prescribed an amphetamine to help manage a diagnosis of attention deficient hyperactivity disorder. To best minimize the risk of abuse and/or overdose, the nurse expects that the medication will be administered via which method? - correct answer Transdermal patch A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor? - correct answer Lack of naturally occurring endorphins To create a safe environment for the client diagnosed with major depression with psychotic features, the nurse most importantly devises a plan of care that deals specifically with which problem? - correct answer Disturbed thinking Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply. - correct answer -The client will keep scheduled appointments. - The client's physical wounds will begin to heal properly. -The client will verbalize feelings about the abusive event. - The client will participate in the various aspects of the treatment plan. Which is the best therapeutic approach for the nurse to use in crisis counseling? - correct answer Active, with focus on the current situation A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which are the most realistic goals for this client? Select all that apply. - correct answer - The client will develop adaptive coping patterns. - The client will identify a realistic perception of stressors - The client will express and share feelings regarding the present crisis. - The client will identify effective coping patterns that have worked in the past. The nursing care plan indicates a problem of self-directed violence and the risk for suicide, related to suicidal ideations with a specific plan. The nurse develops a plan of care for the client and identifies which expected client outcome? - correct answer Denies presence of suicidal ideations What is an appropriate short-term outcome for a client grieving the recent loss of a spouse? - correct answer The client verbalizes stages of grief and plans to attend a community grief group. A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? - correct answer "I hear what you are saying, but I have no reason to believe your roommate steals." A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? - correct answer "You seem very distressed over learning you have asthma." A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic? - correct answer "You need to grieve, and expressing anger can be part of grieving." nyctophobia - correct answer fear of the dark When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration? - correct answer Assessing all activities for safety risks The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? - correct answer "Our relationship is a therapeutic and helping one." The client asks the nurse, "Could you ask the health care provider (HCP) to let me have a pass for the weekend?" Which response is appropriate that assists the client in achieving the goal of optimal personal functioning? - correct answer "When the HCP arrives on the unit, I will let them know that you have a question." Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship? - correct answer Establishing the parameters of the relationship The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Based on this fact, what assumption can the nurse make about the client? - correct answer The client has the right to demand and obtain release from the hospital. The client diagnosed with mild depression says to the nurse, "I haven't had an appet [Show Less]
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A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes rig... [Show More] ht for me." which response by the nurse demonstrates therapeutic communication? 1. "You have everything to live for" 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?" - correct answer 4. "You've been feeling like a failure for a while?" The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. "Sometimes I have trouble sleeping too" - correct answer 3. "You're having difficulty sleeping?" A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition - correct answer 1. Using open-ended questions and silence The nurse should plan which goals of the termination stage of group development? Select all that apply. 1. The group evaluates the experience 2. The real work of the group is accomplished 3. Group interaction involves superficial conversation 4. Group members become acquainted with one another 5. Some structuring of group norms, roles, and responsibilities takes place. 6. The group explores members' feelings about the group and the impending separation. - correct answer 1. The group evaluates the experience 6. The group explores members' feelings about the group and the impending separation. A client is diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis." - correct answer 3. "You're feeling angry that your family continues to hope for you to be cured?" On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior? 1. Fearfulness regarding treatment measures 2. Anger and aggressiveness directed towards others 3. An understanding of the pathology and symptoms of the diagnosis 4. A willingness to participate in the planning of the care and treatment plan - correct answer 4. A willingness to participate in the planning of the care and treatment plan A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1. Contact the clients health care provider (HCP) 2. Call the clients family to arrange for transportation. 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely results in an involuntary commitment - correct answer 1. Contact the clients health care provider (HCP) When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1. Monitor closely for harm to self and others 2. Assist in completing an application for admission 3. Supply the client with written information about his or her mental illness 4. Provide an opportunity for the family to discuss why they felt the admission was needed. - correct answer 1. Monitor closely for harm to self and others When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs - correct answer 4. Helping the client to examine dysfunctional thoughts and beliefs A client is preparing to attend a Gamblers anonymous meeting for the first time. The nurse should tell the client that which is the first stop in this 12 step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble - correct answer 1. Admitting to having a problem The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is carol doing?" she is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about carol, you need to ask her yourself." 3. "Only because you're worried about a friend. I'll tell you that she is improving" 4. "Being her friend, you know she is having a difficult time and deserves her privacy" - correct answer 1. "I cannot discuss any client situation with you." The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment - correct answer 2. Battery 3. Assault 5. False imprisonment The nurse is a mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply 1. Restating 2. Listening 3. Asking the client "why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval of disapproval - correct answer 1. Restating 2. Listening 4. Maintaining neutral responses 5. Providing acknowledgment and feedback What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only 2. Refer the client to another group that includes other manic clients 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that others now need a chance to contribute. - correct answer 4. Thank the client for the input, but inform the client that others now need a chance to contribute. A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach? 1. Milieu therapy 2. Interpersonal therapy 3. Behavior modification 4. Support group therapy - correct answer 1. Milieu therapy The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the clients potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping - correct answer 4. Inquiring about and examining the client's feelings for any that may block adaptive coping The nurse provides an educational sessions on client rights. Which statement by a member of the session demonstrates the best understanding of the nurses role regarding ensuring that each client's rights are respected? 1. "Autonomy is the fundamental right of each and every client" 2. "A clients rights are guaranteed by both state and federal laws" 3. "Being respectful and concerned will ensure that i'm attentive to my clients rights." 4. "Regardless of the client's condition, all nurses have the duty to value client rights" - correct answer 3. "Being respectful and concerned will ensure that i'm attentive to my clients rights." A client says to the nurse, "the federal guards were sent to kill me." which is the best response by the nurse to the client's concern? 1. "I don't believe this is true" 2. "The guards are not out to kill you" 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?" - correct answer 3. "Do you feel afraid that people are trying to hurt you?" A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurses station 2. Use an indirect light source to turn off the television 3. Keep the television and a soft light on during the night 4. Play soft music during the night, and maintain a well-lit room - correct answer 2. Use an indirect light source to turn off the television A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2. Identification of the physical activities that will provide exercise 3. No socializing activities, until the client asks to participate in milieu 4. A structured program of activities in which the client can participate - correct answer 4. A structured program of activities in which the client can participate When planning for the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations - correct answer 2. Identifying anxiety-producing situations A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1. Avoidant 2. Borderline 3. Schizotypal 4. Obsessive compulsive - correct answer 1. Avoidant The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the groups interactions, which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend another group sessions. - correct answer 1. Setting limits on the client's behavior A client is admitted to the medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult? 1. Psychosis 2. repression 3. conversion disorder 4. dissociative disorder - correct answer 3. conversion disorder A manic client begins to make sexual advances towards visitors in the day room. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of the situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are being revoked for 24 hours. - correct answer 3. Escort the client to their room, with the assistance of other staff. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. This is the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a non punitive manner. 5. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. 6. Have a client state the consequences for behaving in ways that are viewed as unacceptable - correct answer 1. Communicate expected behaviors to the client. 3. This is the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a non punitive manner. 6. Have a client state the consequences for behaving in ways that are viewed as unacceptable The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client speech pattern is rapid, in affect is belligerent. Based on these observations which is the nurses immediate priority of care? 1. Provide safety for the client other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff and caring for the client in a controlled environment. 4. Offer the client a less stimulating area in which to calm down and gain control. - correct answer 1. Provide safety for the client other clients on the unit. The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggest to the nurse that the client has a need for additional information? 1. My medication will help my anxious feelings. 2. I'll go to support groups and talk about what I am feeling. 3. I need to get enough sleep and eat well to help prevent feeling anxious. 4. When I have command hallucinations, I'll call a friend and ask him what I should do. - correct answer 4. When I have command hallucinations, I'll call a friend and ask him what I should do. The nurse is caring for a client just admitted to the mental health unit in diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? 1. As direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the day room with other clients so they can help watch them. - correct answer 3. Sit beside the client in silence with occasional open-ended questions. The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought process is. In formulating a nursing plan of care, which best intervention should the nurse include? 1. Increase socialization of the client with peers. 2. Avoid using a whisper voice in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have a client sign a release of information to appropriate parties for assessment purposes. - correct answer 2. Avoid using a whisper voice in front of the client. Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply 1. Monitor vital signs 2. Provide a safe environment 3. Address hallucinations therapeutically 4. Provide stimulation in the environment 5. Provide reality orientation as appropriate 6. Maintain NPO status - correct answer 1. Monitor vital signs 2. Provide a safe environment 3. Address hallucinations therapeutically 5. Provide reality orientation as appropriate The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me" 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence" 3. "I enjoy attending the meetings because they get me out of the house and away from my husband" 4. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics" - correct answer 1. "I no longer feel that I deserve the beatings my husband inflicts on me" A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor 2. Call security to block all exit areas 3. Restrain the client until the HCP can be reached 4. Tell the client that the client cannot return to this hospital again if the client leaves now. - correct answer 1. Call the nursing supervisor The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply 1. Dental decay 2. Moist oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range - correct answer 1. Dental decay 3. Loss of tooth enamel 4. Electrolyte imbalances The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately 2. Interrupt the client and offer to take her for a walk 3. Allow the client to complete her exercise program 4. Tell the client she is not allowed to exercise rigorously - correct answer 2. Interrupt the client and offer to take her for a walk A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa. 1. A client with pneumonia. 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at meal time - correct answer 2. A client undergoing diagnostic tests The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations - correct answer 4. Hypertension, changes in level of consciousness, hallucinations The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? 1. "Why don't you tell your spouse about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision" 4. "I agree with you. You should get out of this situation" - correct answer 2. "What do you find difficult about this situation?" A client with anorexia nervosa is a member of a pre-discharge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake by 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge - correct answer 2. Evidence of the client's disturbed body image The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now? 2. "You will need to be placed in seclusion" 3. "You seem restless; tell me what is happening" 4. "You will need to be restrained if you do not change your behavior" - correct answer 3. "You seem restless; tell me what is happening" The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experience by the client - correct answer 2. The death of a loved one The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?" - correct answer 3. "What leads you to seek help now?" The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness 2. A crisis state indicates that the client has an emotional illness 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for one client may not constitute a crisis for another client. - correct answer 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for one client may not constitute a crisis for another client. The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 1. Signs of depression 2. Reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission - correct answer 2. Reactions to a devastating event A depressed client on an inpatient unity says to the nurse, "My family would be better off without me." Which is the nurse's best response? 1. "Have you talked to your family about this" 2. "Everyone feels this way when they are depressed" 3. "You will feel better once your medication begins to work" 4. "You sound very upset. Are you thinking of hurting yourself?" - correct answer 4. "You sound very upset. Are you thinking of hurting yourself?" The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. 1. Initiate confinement measures 2. Acknowledge the client's behavior 3. Assist the client to an area that is quiet 4. Maintain a safe distance from the client 5. Allow the client to take control of the situation - correct answer 2. Acknowledge the client's behavior 3. Assist the client to an area that is quiet 4. Maintain a safe distance from the client Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and to her room 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking. - correct answer 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? 1. Administer an antianxiety agent 2. Assess and treat the wound sites 3. Secure and record a detailed history 4. Encourage and assist the client to ventilate feelings - correct answer 2. Assess and treat the wound sites A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I am finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of this medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed - correct answer 3. Increasing the level of suicide precautions The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-min checks 3. Checking the whereabouts of the client every 15 min 4. Asking the client to report suicidal thoughts immediately - correct answer 1. One-to-one suicide precautions The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation - correct answer 1. Information regarding shelters A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur" 2. "It will take some time to get over these feelings about your rape" 3. "Tell me more about the incident that causes you to feel like the rape just occurred" 4. "What do you think you can do to alleviate some of your fears about being raped again?" - correct answer 3. "Tell me more about the incident that causes you to feel like the rape just occurred" A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning to the client a staff member who will remain with the client at all times 4. Admitting the client to a seclusion room were all potentially dangerous articles are removed - correct answer 3. Assigning to the client a staff member who will remain with the client at all times A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply 1. "I am afraid of spiders" 2. "I keep reliving the robbery" 3. "I see his face everywhere I go" 4. "I don't want anything to eat now" 5. "I might have died over a few dollars in my pocket" 6. "I have to wash my hands over and over again many times" - correct answer 2. "I keep reliving the robbery" 3. "I see his face everywhere I go" 5. "I might have died over a few dollars in my pocket" A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose? 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. As needed when the client complains of depression - correct answer 2. At the same time each evening A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count - correct answer 4. White blood cell count A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety? 1. Take the medication only with meals 2. Take the medication at the same time each day 3. Use a dose container to help prevent missed doses 4. Avoid drinking alcohol while taking this medication - correct answer 4. Avoid drinking alcohol while taking this medication The nurse is describing the medication side and adverse effects to a client who is taking oxazepam. Which information should the nurse incorporate in the discussion? 1. Consume a low-fiber diet 2. Increase fluids and built in the diet 3. Rest if the heart begins to beat rapidly 4. Take antidiarrheal agents if diarrhea occurs - correct answer 2. Increase fluids and built in the diet The nurse is administering risperidone to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight 2. Continue driving as usual 3. Avoid foods rich in potassium [Show Less]
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MENTAL_HEALTH_FINAL_EXAM_PRACTICE_QUESTIONS___ANSWERS_LATEST_2022
6. A nursing student new to psychiatric-mental health nursing asks a peer what resources he can use to figure out which symptoms are present in a specific ... [Show More] psychiatric disorder. The best answer would be: a. Nursing Interventions Classification (NIC) b. Nursing Outcomes Classification (NOC) c. NANDA-I nursing diagnoses d. DSM-5 7. Epidemiological studies contribute to improvements in care for individuals with mental disorders by: a. Providing information about effective nursing techniques. b. Identifying risk factors that contribute to the development of a disorder. c. Identifying individuals in the general population who will develop a specific disorder. d. Identifying which individuals will respond favorably to a specific treatment. 1. Besides antianxiety agents, which classification of drugs is also commonly given to treat anxiety and anxiety disorders? a. Antipsychotics b. Mood stabilizers c. Antidepressants d. Cholinesterase inhibitors 2. What assessment question will provide the nurse with information regarding the effects of a woman‟s circadian rhythms on her quality of life? a. “How much sleep do you usually get each night?” b. “Does your heart ever seem to skip a beat?” c. “When was the last time you had a fever?” d. “Do you have problems urinating?” 3. You realize that your patient who is being treated for a major depressive disorder requires more teaching when she makes the following statement: a. “I have been on this antidepressant for 3 days. I realize that the full effect may not happen for a period of weeks.” b. “I am going to ask my nurse practitioner to discontinue my Prozac today and let me start taking a monoamine oxidase inhibitor tomorrow.” c. “I may ask to have my medication changed to Wellbutrin due to the problems I am having being romantic with my wife.” d. “I realize that there are many antidepressants and it might take a while until we find the one that works best for me.” 4. A patient being treated for insomnia is prescribed ramel-teon (Rozerem). Which comorbid mental health condition would make this medication the hypnotic of choice for this particular patient? a. Obsessive-compulsive disorder b. Generalized anxiety disorder c. Persistent depressive disorder d. Substance use disorder 5. Which statement made by a patient prescribed bupropion (Wellbutrin) demonstrates that the medication education the patient received was effective? Select all that apply. a. “I hope Wellbutrin will help my depression and also help me to finally quit smoking.” b. “I‟m happy to hear that I won‟t need to worry too much about weight gain.” c. “It‟s okay to take Wellbutrin since I haven‟t had a seizure in 6 months.” d. “I need to be careful about driving since the medication could make me drowsy.” e. “My partner and I have discussed the possible effects this medication could have on our sex life.” 6. Which drug group calls for nursing assessment for development of abnormal movement disorders among individuals who take therapeutic dosages? a. SSRIs b. antipsychotics c. benzodiazepines d. tricyclic antidepressants 9. The nurse administers each of the following drugs to various patients. The patient who should be most carefully assessed for fluid and electrolyte imbalance is the one receiving: a. lithium (Eskalith) b. clozapine (Clozaril) c. diazepam (Valium) d. amitriptyline 10. A psychiatric nurse is reviewing prescriptions for a patient with major depression at the county clinic. Since the patient has a mild intellectual disability, the nurse would question which classification of antidepressant drugs: a. Selective serotonin reuptake inhibitors b. Monoamine oxidase inhibitors c. Serotonin and norepinephrine reuptake inhibitors d. All of the above 4. The mental health team is determining treatment options for a male patient who is experiencing psychotic symptoms. Which question(s) should the team answer to determine whether a community outpatient or inpatient setting is most appropriate? Select all that apply. a. “Is the patient expressing suicidal thoughts?” b. “Does the patient have intact judgment and insight into his situation?” c. “Does the patient have experiences with either community or inpatient mental healthcare facilities?” d. “Does the patient require a therapeutic environment to support the management of psychotic symptoms?” e. “Does the patient require the regular involvement of their family/significant other in planning and executing the plan of care?” 10. Pablo is a homeless adult who has no family connection. Pablo passed out on the street and emergency medical services took him to the hospital where he expresses a wish to die. The physician recognizes evidence of substance use problems and mental health issues and recommends inpatient treatment for Pablo. What is the rationale for this treatment choice? Select all that apply. a. Intermittent supervision is available in inpatient settings. b. He requires stabilization of multiple symptoms. c. He has nutritional and self-care needs. d. Medication adherence will be mandated. e. He is in imminent danger of harming himself. 1. Which statement made by the nurse demonstrates the best understanding of nonverbal communication? a. “The patient‟s verbal and nonverbal communication is often different.” b. “When my patient responds to my question, I check for congruence between verbal and nonverbal communication to help validate the response.” c. “If a patient is slumped in the chair, I can be sure he‟s angry or depressed.” d. “It‟s easier to understand verbal communication that nonverbal communication.” 2. Which nursing statement is an example of reflection? a. “I think this feeling will pass.” b. “So you are saying that life has no meaning.” c. “I‟m not sure I understand what you mean.” d. “You look sad.” 3. When should a nurse be most alert to the possibility of communication errors resulting in harm to the patient? a. Change of shift report b. Admission interviews c. One-to-one conversations with patients d. Conversations with patient families 4. During an admission assessment and interview, which channels of information communication should the nurse be monitoring? Select all that apply. a. Auditory b. Visual c. Written d. Tactile e. Olfactory 5. What principle about nurse-patient communication should guide a nurse‟s fear about “saying the wrong thing” to a patient? a. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation. b. The patient is more interested in talking to you than listening to what you have to say and so is not likely to be offended. c. Considering the patient‟s history, there is little chance that the comment will do any actual harm. d. Most people with a mentally illness have by necessity developed a high tolerance of forgiveness. 6. You have been working closely with a patient for the past month. Today he tells you he is looking forward to meeting with his new psychiatrist but frowns and avoids eye contact while reporting this to you. Which of the following responses would most likely be therapeutic? a. “A new psychiatrist is a chance to start fresh; I‟m sure it will go well for you.” b. “You say you look forward to the meeting, but you appear anxious or unhappy.” c. “I notice that you frowned and avoided eye contact just now. Don‟t you feel well?” d. “I get the impression you don‟t really want to see your psychiatrist—can you tell me why?” 7. Which student behavior is consistent with therapeutic communication? a. Offering your opinion when asked to convey support. b. Summarizing the essence of the patient‟s comments in your own words. c. Interrupting periods of silence before they become awkward for the patient. d. Telling the patient he did well when you approve of his statements or actions. 8. James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for day shift and anxiously reports, “Last night, demons came to my room and tried to rape me.” Which response would be most therapeutic? a. “There are no such things as demons. What you saw were hallucinations.” b. “It is not possible for anyone to enter your room at night. You are safe here.” c. “You seem very upset. Please tell me more about what you experienced last night.” d. “That must have been very frightening, but we‟ll check on you at night and you‟ll be safe.” 9. Therapeutic communication is the foundation of a patient- centered interview. Which of the following techniques is not considered therapeutic? a. Restating b. Encouraging description of perception c. Summarizing d. Asking “why” questions 10. Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, “I don‟t need to come see you anymore. I have found a therapy app on my phone that I love.” How should Carolina respond to this news? a. “That sounds exciting, would you be willing to visit and show me the app?” b. “At this time, there is no real evidence that the app can replace our therapy.” c. “I am not sure that is a good idea right now, we are so close to progress.” d. “Why would you think that is a better option than meeting with me?” 1. Which statement demonstrates a well-structured attempt at limit setting? a. “Hitting me when you are angry is unacceptable.” b. “I expect you to behave yourself during dinner.” c. “Come here, right now!” d. “Good boys don‟t bite.” 2. Which activity is most appropriate for a child with ADHD? a. Reading an adventure novel b. Monopoly c. Checkers d. Tennis 3. Cognitive-behavioral therapy is going well when a 12-year- old patient in therapy reports to the nurse practitioner: a. “I was so mad I wanted to hit my mother.” b. “I thought that everyone at school hated me. That‟s not true. Most people like me and I have a friend named Todd.” c. “I forgot that you told me to breathe when I become angry.” d. “I scream as loud as I can when the train goes by the house.” 4. What assessment question should the nurse ask when attempting to determine a teenager‟s mental health resilience? Select all that apply. a. “How did you cope when your father deployed with the Army for a year in Iraq?” b. “Who did you go to for advice while your father was away for a year in Iraq?” c. “How do you feel about talking to a mental health counselor?” d. “Where do you see yourself in 10 years?” e. “Do you like the school you go to?” 5. Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply. a. Limited language skills b. Level of cognitive development c. Level of emotional development d. Parental denial that a problem exists e. Severity of the typical mental illnesses observed in young children 7. In pediatric mental health there is a lack of sufficient numbers of community-based resources and providers, and there are long waiting lists for services. This has resulted in: Select all that apply. a. Children of color and poor economic conditions being underserved b. Increased stress in the family unit c. Markedly increased funding d. Premature termination of services 8. Child protective services have removed 10-year-old Christopher from his parents‟ home due to neglect. Christopher reveals to the nurse that he considers the woman next door his “nice” mom, that he loves school, and gets above average grades. The strongest explanation of this response is: a. Temperament b. Genetic factors c. Resilience d. Paradoxical effects of neglect 9. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April‟s mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that: a. Time-out is an important part of April‟s baseline discipline. b. Time-out is no longer an effective therapeutic measure. c. April enjoys time-out, and acts out to get some alone time. d. Time-out will need to be replaced with seclusion and restraint. 10. Adolescents often display fluctuations in mood along with undeveloped emotional regulation and poor tolerance for frustration. Emotional and behavioral control usually increases over the course of adolescence due to: a. Limited executive function b. Cerebellum maturation c. Cerebral stasis and hormonal changes d. A slight reduction in brain volume 1. Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia? a. Always afraid another student will steal her belongings. b. An unusual interest in numbers and specific topics. c. Demonstrates no interest in athletics or organized sports. d. Appears more comfortable among males. 2. Which nursing intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia? a. Screening a group of males between the ages of 15 and 25 for early symptoms. b. Forming a support group for females aged 25 to 35 who are diagnosed with substance use issues. c. Providing a group for patients between the ages of 45 and 55 with information on coping skills that have proven to be effective. d. Educating the parents of a group of developmentally delayed 5- to 6-year-olds on the importance of early intervention. 3. To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply. a. Alcohol use disorder b. Major depressive disorder c. Stomach cancer d. Polydipsia e. Metabolic syndrome 4. A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms? a. Her memory problems will likely decrease. b. Depressive episodes should be less severe. c. She will probably enjoy social interactions more. d. She should experience a reduction in hallucinations. 5. Which characteristic presents the greatest risk for injury to others by the patient diagnosed with schizophrenia? a. Depersonalization b. Pressured speech c. Negative symptoms d. Paranoia 6. Gilbert, age 19, is described by his parents as a “moody child” with an onset of odd behavior about at age 14, which caused Gilbert to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert‟s early and slow onset of what is now recognized as schizophrenia, his prognosis is considered: a. Favorable with medication b. In the relapse stage c. Improvable with psychosocial interventions d. To have a less positive outcome 7. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient‟s nursing diagnosis is altered thought processes? a. “I know you say you hear voices, but I cannot hear them.” b. “Stop listening to the voices, they are NOT real.” c. “You say you hear voices, what are they telling you?” d. “Please tell the voices to leave you alone for now.” 8. When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that: a. Medications provided are ineffective. b. Nurses are trying to control their minds. c. The medications will make them sick. d. They are not actually ill. 9. Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply. a. Hold his medication and contact his prescriber. b. Wipe him with a washcloth wet with cold water or alcohol. c. Administer a medication such as benztropine IM to correct this dystonic reaction. d. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. e. Hold his medication for now and consult his prescriber when he comes to the unit later today. 10. Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas‟s nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co- occur along with: a. Generally good health despite the mental illness. b. An aversion to drinking fluids. c. Anxiety and depression. d. The ability to express his needs. 1. Which nursing response demonstrates accurate information that should be discussed with the female patient diagnosed with bipolar and her support system? Select all that apply. a. “Remember that alcohol and caffeine can trigger a relapse of your symptoms.” b. “Due to the risk of a manic episode, antidepressant therapy is never used with bipolar disorder. c. “It‟s critical to let your healthcare provider know immediately if you aren‟t sleeping well.” d. “Is your family prepared to be actively involved in helping manage this disorder?” e. “The symptoms tend to come and go and so you need to be able to recognize the early signs.” 2. Which statement made by the patient demonstrates an understanding of the effective use of newly prescribed lithium to manage bipolar mania? Select all that apply. a. “I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day.” b. “I discussed the diuretic my cardiologist prescribed with my psychiatric care provider.” c. “Lithium may help me lose the few extra pounds I tend to carry around.” d. “I take my lithium on an empty stomach to help with absorption.” e. “I‟ve already made arrangements for my monthly lab work.” 3. The nurse is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the nurse stress to the patient? Select all that apply. a. Increased attentiveness b. Getting up at night to urinate c. Improved vision d. An upset stomach for no apparent reason e. Shaky hands that make holding a cup difficult 4. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially? a. Reinforce that the level is considered therapeutic. b. Instruct the patient to hold the next dose of medication and contact the prescriber. c. Have the patient go to the hospital emergency room immediately. d. Alert the patient to the possibility of seizures and appropriate precautions. 5. Which intervention should the nurse implement when caring for a patient demonstrating manic behavior? Select all that apply. a. Monitor the patient‟s vital signs frequently. b. Keep the patient distracted with group-oriented activities. c. Provide the patient with frequent milkshakes and protein drinks. d. Reduce the volume on the television and dim bright lights in the environment. e. Use a firm but calm voice to give specific concise directions to the patient. 6. Substance abuse is often present in people diagnosed with bipolar disorder. Laura, a 28-year- old with a diagnosis of bipolar disorder, drinks alcohol instead of taking her prescribed medications. The nurse caring for this patient recognizes that: a. Anxiety may be present. b. Alcohol ingestion is a form of self-medication. c. The patient is lacking a sufficient number of neurotransmitters. d. The patient is using alcohol because she is depressed. 7. Ted, a former executive, is now unemployed due to manic episodes at work. He was diagnosed with bipolar I 8 years ago. Ted has a history of IV drug abuse, which resulted in hepatitis C. He is taking his lithium exactly as scheduled, a fact that both Ted‟s wife and his blood tests confirm. To reduce Ted‟s mania the psychiatric nurse practitioner recommends: a. Clonazepam (Klonopin) b. Fluoxetine (Prozac) c. Electroconvulsive therapy (ECT) d. Lurasidone (Latuda) 8. A 33-year-old female diagnosed with bipolar I disorder has been functioning well on lithium for 11 months. At her most recent checkup, the psychiatric nurse practitioner states, “You are ready to enter the maintenance therapy stage, so at this time I am going to adjust your dosage by prescribing”: a. A higher dosage b. Once a week dosing c. A lower dosage d. A different drug 9. Tatiana has been hospitalized for an acute manic episode. On admission the nurse suspects lithium toxicity. What assessment findings would indicate the nurse‟s suspicion as correct? a. Shortness of breath, gastrointestinal distress, chronic cough b. Ataxia, severe hypotension, large volume of dilute urine c. Gastrointestinal distress, thirst, nystagmus d. Electroencephalographic changes, chest pain, dizziness 10. Luc‟s family comes home one evening to find him extremely agitated and they suspect in a full manic episode. The family calls emergency medical services. While one medic is talking with Luc and his family, the other medic is counting something on his desk. What is the medic most likely counting? a. Hypodermic needles b. Fast food wrappers c. Empty soda cans d. Energy drink containers 1. Which response by a 15-year-old demonstrates a common symptom observed in patients diagnosed with major depressive disorder? a. “I‟m so restless. I can‟t seem to sit still.” b. “I spend most of my time studying. I have to get into a good college.” [Show Less]
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