1. A client with paranoia is admitted to the mental health unit
and immediately goes to the corner of the room and sits
quietly without communicating.
... [Show More] In approaching the client,
what intervention should the nurse implement first?
• Explain the nurse's role to the client.
2. client treated with lithium for bipolar develops
diarrhea, vomiting and drowsiness, what action should
the nurse do
• Notify HCP of the symptoms prior to the next admin of
the drug
3. A mental health worker (MHW) is caring for a client
with escalating aggressive behavior, which action by
the MHW warrants immediate intervention by the
nurse?
• Is attempting to physically restrain the client.
4. woman who is bipolar is wearing low cut blouse, and skirt
with no underwear, what does nurse do?
• Walk her to room and help her pick out something
more appropriate
5. Older man who recently got divorced and is 2 years sober,
and an alcoholic loves God. He loves kids also. What should
nurse ask at his initial interaction?
• What is your biggest concern?
6. Woman is diagnosed with breast cancer and she becomes
dependent and asks family members if they can do ADL's
that she is fully capable of doing. What is the reason for
this behavior?
• Its expected; regression is a natural start for recovery
7. Patient having to get treated for benzodiazepam
and methadone overdose. What do you use?
• Narcan
8. Patient watching TV starts talking loud to himself. The
nurse comes in and can't distract him so turns down the
TV. What should the nurse do then?
• Move client to quieter room
9. In group therapy the charge nurse notices a client
increasing to severe levels of anxiety. What should the nurse
do?
• Talk in a calm, approaching manner
10. A chronic depressed older man refuses to leave his room.
His family moved away to a further location so they're not
able to visit him as much. What approach should the nurse
take with this man?
• May I lay with you for a little?
11. Patient who is really depressed and won't talk or
communicate, later is energetic and talkative. What should
the nurse do?
• Closely monitor the patient (could be suicidal)
12. Patient who had generalized anxiety disorder on Xanax
long- term. What is the outcome?
• Importance of not quickly stopping the drug
13. Mother has a 9-month old baby with mental issues and
growth issues. The mother comes in and says she's
depressed because she’ll never have a normal baby. What
should the nurse say?
• Have you had any thoughts of harming your baby
or yourself?
14. Lithium level 1.5. What do you tell the client who had a
recent suicide attempt after seeing him become very
anxious after hearing his Lithium levels?
• drink 2-3L of water in 24 hours
15. Woman comes into ED having been raped by her date.
What should the nurse document?
• document she stated "I was raped by my date"
16. Which patient would require CAGE assessment?
• Alcohol patient, cut down, annoyed, guilty, eye opener
17. A nurse is changing a dressing on a bipolar patient's
stomach from self-inflicting knife wound. What is the
nurse's best approach?
• showing no signs of being judgmental
18. Woman is at a meeting with you, what is important for
the nurse to document after hearing her issues in the
relationship [Show Less]