PN MENTAL HEALTH ONLINE PRACTICE A
LATEST UPDATE 2022/2023
A nurse is reinforcing teaching with a client whose provider has prescribed
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electroconvulsive therapy (ECT). Which of the following information should the nurse
include? - ANS-C. ECT is an option for clients after medication has been
unsuccessful.
(Medication is the first-line of treatment for depression. ECT is prescribed when
medication has been unsuccessful.)
A nurse is assisting with discharge planning for a client who needs to attend a day
treatment center ad has limited community and financial support. Which of the
following referrals should the nurse recommend including in the client's discharge
plan? - ANS-A. Social worker (Social workers can assist clients with building a
support structure to help promote and preserve mental health, including contacting
day treatment centers and arranging for financial and other community resources.)
A nurse is developing countertransference toward a client during the working phase
of the nurse-client relationship. To correct the situation, which of the following actions
should the nurse take? - ANS-D. identify personal response to the client.
(Countertransference is an emotional response toward the client by the nurse. This
response might be related to the nurse's past unresolved feelings or relationships.
These feelings can interfere with the nurse-client therapeutic relationship. In order to
correct the situation of countertransference, the nurse must recognize personal
reactions to the client in an attempt to work through these feelings.)
A nurse is collecting data from a client who has bipolar and a history of mania. Which
of the following findings should the nurse identify as an indication that the client is
relapsing? - ANS-B. Pressured speech (The nurse should identify that rapid or
pressured speech, provocative behavior, and insomnia are indications of potential
relapse in a client who has bipolar disorder and a history of mania.)
History and Physical
Subjective: Client states, "My stomach hurts."; "I feel sadder and more alone every
day."
Client's adult child stated to the nurse upon dropping the client off today, "I've been
meaning to tell you, I started giving my dad St. John's wort several weeks ago to
improve his mood."
Objective: Episodes of speech incoherency, rapid mood swings, 3 episodes of
vomiting in the past 40 min
Moderate Alzheimer's disease.
Provider Prescriptions
Fluoxetine 20 mg PO daily
Trazodone 50 mg PO daily at bedtime
Omeprazole 20 mg PO daily
Diagnostic Results
Blood pressure 172/94 mm Hg
Temperature 38.2° C (100.8° F)
Pulse rate 110/min
Respiratory rate 24/min
A nurse is caring for a client in a day treatment program. Which of the following
actions should the nurse take? (Click on the exhibit tabs for additional information
about the client. There are three tabs that contain separate categories of data)
A. Request transport for the client to an emergency department.
B. Place a hypothermia blanket on the client. (There is no indication that a
hypothermia blanket is necessary for this client.)
C. Discontinue the client's fluoxetine therapy immediately. (Fluoxetine should not be
discontinued abruptly because this can cause the client to exhibit manifestations of
withdrawal.)
D. Implement droplet precautions for the client. (There is no indication for the
implementation of droplet precautions for this client. Droplet precautions are used for
clients who have diseases that are transmitted by large droplets that are expelled
into the air.) - ANS-A. Request transport for the client to an emergency department.
(The nurse should request transport for the client to the nearest emergency
department because the client has manifestations of serotonin syndrome. Serotonin
syndrome is a life-threatening syndrome and is caused by an over activation of the
central serotonin receptors. This is related to interactions with taking an SSRI and
trazodone along with St. John's wort. Manifestations of serotonin syndrome include
hypertension, tachycardia, vomiting, abdominal pain, and mental status changes.)
A nurse is preparing to administer clozapine for the first time to a client who has
schizophrenia. The nurse explains the therapeutic and adverse effects of the
medication to the client prior to administration. which of the following ethical
concepts is the nurse demonstrating?
A. Autonomy (Autonomy involves respecting the client's right to make their own
decision. The nurse is currently providing information. The client has not made a
decision yet about taking the medication.)
B. Justice (Justice means distributing care or resources equally among clients or
groups of clients. The nurse is currently caring for an individual client who requires
information about a prescribed medication.)
C. Veracity
D. Confidentiality (Confidentiality means respecting the client's privacy regarding
personal issues. The nurse should uphold this ethical principle when making
decisions about sharing client information with others.) - ANS-C. Veracity (Veracity is
the duty to tell the truth. The nurse should uphold this ethical principle when
administering a new medication to a client by explaining the therapeutic effects as
well as the adverse effects. This action promotes a trusting relationship between the
nurse and the client, which enhances the nurse's primary commitment to the client of
providing optimum, quality care.)
A nurse is preparing to administer haloperidol 3 mg IM to a client. Available is
haloperidol solution 5 mg/mL. How many mL should the nurse plan to administer? -
ANS-5 mg3 mg = 1 mL X mL
X mL = 0.6 mL
Step 7: Round if necessary
A nurse is caring for a client who has anxiety disorder and is refusing to take a
medication which of the following responses should the nurse make?
A. "This medication is safe for you to take." (This response devalues the client's
concerns, gives false reassurance, and discourages further communication about
the motivation behind the client's refusal.)
B. "You have the right to refuse this medication."
C. "You are presenting a risk to the other clients." (This response places blame on
the client and rejects their choice without exploring the motivation behind it.)
D. "This medication is part of your treatment plan." (This response fails to encourage
the client to explore their feelings of anxiety and to participate in devising or
accepting strategies to manage it) - ANS-B. "You have the right to refuse this
medication." ( Clients have the right to refuse treatment, including medications,
unless the client undergoes a court hearing and the judge decides that the client
meets the criteria for involuntary medication administration.)
A nurse is collecting data from a client who has paranoid personality disorder. Which
of the following manifestations should the nurse expect.
A. Preoccupied with perfectionism (The nurse should expect a client who has
obsessive-compulsive personality disorder to have manifestations of being
preoccupied with details.)
B. Uses attention-seeking behaviors (The nurse should expect a client who has
histrionic personality disorder to have manifestations of attention-seeking behaviors.)
C. Exploitative of others (The nurse should expect a client who has antisocial
behavior to have manifestations of exploiting others.)
D. Projects blame onto others - ANS-D. Projects blame onto others (The nurse
should expect clients who have paranoid personality disorder to project blame onto
others rather than taking responsibility for their own actions.)
A nurse is caring for a client who is 2 days post-op following a hip arthroplasty. When
a news report about military action comes on the television, the client says to the
nurse. "My youngest child died 6 months ago while serving in the military." Which of
the following responses should the nurse make? (Select all that apply)
A. "This must be a very difficult time for you."
B. "Your child's death must be a terrible loss."
C. "It's just awful what is going on in the world." is incorrect. (This statement
demonstrates a nontherapeutic response because it changes the subject and diverts
attention away from the client's grief. This belittles and invalidates the client's
feelings.)
D. "You need to focus on getting better." is incorrect. (This statement demonstrates a
nontherapeutic response because it negates the client's feelings and makes the
assumption that the nurse knows best. This prevents problem-solving and can cause
the client to feel misunderstood, insignificant, and unsupported.)
E. "Tell me something you remember about your child." - ANS-A. "This must be a
very difficult time for you." (This statement demonstrates the use of reflecting.
Reflecting expresses the nurse's observations of the client's verbal and nonverbal
behaviors when discussing sensitive issues. This therapeutic communication
technique encourages clients to accept and embrace their own feelings.)
B. "Your child's death must be a terrible loss." (This statement demonstrates the use
of reflecting. Reflecting expresses the nurse's observations of the client's verbal and
nonverbal behaviors when discussing sensitive issues. This therapeutic
communication technique encourages clients to accept and embrace their own
feelings.)
E. "Tell me something you remember about your child." (This statement
demonstrates the use of exploring. Exploring acknowledges the client's feelings and
facilitates communication between the client and the nurse.)
A nurse is assisting with screening a group of clients for major depressive disorder
(MDD). The nurse should identify that which of the following clients is at an
increased risk for the development of MDD?
A. A client who is newly employed. (There is a relationship between socioeconomic
class and depression. However, it is not proven that employment status has an effect
on the development of MDD.)
B. A client who abstains from alcohol (Clients who have alcohol or substance use
disorders are at an increased risk for developing MDD.)
C. A client who just gave birth
D. A client who has been married for 15 years (Clients who are married are at a
decreased risk for developing MDD. Marriage or close relationships have been
shown to have a calming effect on the well-being of an individual's psychological
status when compared to those who are single or who lack a close relationship with
another person) - ANS-C. A client who just gave birth (Clients who just gave birth or
are in the early postpartum period are at an increased risk for developing MDD or
postpartum depression.)
A nurse is assisting with the admission of a client who has schizophrenia.
A. Conduct an abnormal involuntary movement scale test.
B. Discuss behavioral expectations with the client. (Discussing behavioral
expectations with the client is important to encourage expected behavior and to
discourage undesirable behavior. However, there is another action that the nurse
should take first.)
C. Orient the client to unit routines. (Orienting the client to unit routines is important
to create a sense of security and promote a therapeutic environment. However, there
is another action that the nurse should take first.)
D. Encourage the client to attend group art sessions. (Participation in art therapy,
such as drawing or listening to music, can assist a client with recognition and
expression of specific feelings. However, there is another action that the nurse
should take first) - ANS-A. Conduct an abnormal involuntary movement scale test.
(The first action the nurse should take when using the nursing process is to collect
data. The abnormal involuntary movement scale (AIMS) test is a data collection tool
used to guide medication therapy for clients who are prescribed antipsychotic
medications. Therefore, the first action the nurse should take is to conduct the AIMS
test.)
A nurse is contributing to the plan of care for a client who has obsessive-compulsive
disorder and continually washes her hands. Which of the following interventions
should the nurse include?
A. Inform the client that excessive handwashing is a negative behavior. (This can
increase anxiety, rather than decrease the need for handwashing, and is not an
effective intervention for the nurse to include in the plan of care.)
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