1. When caring for an older client, the nurse observes multiple bruises in over the client’s legs, arms, back, and gluteal areas. When the client contact... [Show More] , the nurse suspects elder abuse. What action should the nurse?
2. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to e mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the nurse take?
3. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’s wok study program. What action should the nurse take?
4. A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (desyrel) for insomnia. Which information is most important for the nurse to ask this client?
5. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse that he is the son of God. Based on this statement, which intervention should the nurse include in this client’s plan of care?
6. The nurse on the day shift receives report about a client with depression who was in bed most of the weekend. The nurse walks into the client’s room in the morning and finds the client in bed. What intervention I best for the nurse to implement?
7. Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?
8. A female client admitted to the mental health unit stats to shout and scream at the nurse. What is he best approach for the nurse to take?
9. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crows. Which nursing problems applies to the client’s behavior?
10. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client?
11. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate?
12. 10. A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?
13. A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement?
14. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?
15. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?
16. The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?
17. A male client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
18. The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client’s dressing?
19. While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client’s behaviors. What is the main goal of this therapeutic technique?
20. An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?
21. When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide?
22. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?
23. The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?
24. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
25. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?
26. The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT?
27. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?
28. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
29. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
30. A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
31. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
32. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations?
33. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?
34. A female client on a psychiatric unit is sweating profusely while she vigorously does pushups and then runs the length of the corridor several times before crashing in to the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations
35. An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?
36. The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother?
37. The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?
38. Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?
39. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?
40. A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select all that apply).
41. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
42. A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable?
43. A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?
44. The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?
45. A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated?
46. Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
47. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client’s current feelings of depression?
48. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states”I don’t need to be here,” and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam?
49. An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?
50. A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?
51. A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority?
52. The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation?
53. Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)? [Show Less]