Exam 2 Study Mental

A nurse is discussing suicide interventions with nursing staff. which of the following should the nurse identify as an example of secondary intervention?

performing life-saving measures following a suicide attempt

Serum lithium level of 2.0. which of the following is the priority action for the nurse to take?

Notify the primary provider the results indicates toxicity. The therapeutic reference range for lithium is 0.-1.2 mEq/L. The nurse should recognize the client could require hospitalization and report the finding to the provider.

A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

Preparing for artificial ventilation. Delirium, severe vital sign changes, and apnea may be present in the client who has serotonin syndrome. Preparing for artificial ventilation is the priority intervention when taking the airway, breathing, circulation approach to client care.

A nurse on the hospice unit is caring for a newly-admitted client. Which of the following client statements should the nurse report to the provider?

"I plan to take an antiaging supplement to prolong my life"

A nurse is providing teaching to the family of a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements made by the family indicates an understanding of ECT? A. "We are so glad there are no physical side effects of shock treatment." B. "Thank goodness there is no permanent memory loss." C. "Cardiac dysrhythmias can persist for several weeks." D. "We won't be alarmed if there is some confusion after the treatment."

"We won't be alarmed if there is some confusion after the treatment." It is common following ECT for a client to experience confusion and disorientation.

A nurse is teaching a client who has major depressive disorder and is scheduled to begin electroconvulsive therapy (ECT). Which of the following pieces of information should the nurse include? A. "If you're taking a benzodiazepine medication, you should take it before the procedure." B. "You can expect to wake up about 15 minutes after the procedure." C. "After the first procedure, you should expect to have ECT sessions monthly for a year." D. "ECT is the primary treatment for most clients who have depression." Check Answer

"You can expect to wake up about 15 minutes after the procedure." A client who undergoes ECT usually wakes up about 15 minutes after the procedure and can be disoriented for several hours after. Incorrect Answers: A. ECT deliberately causes seizures, and benzodiazepine use prevents therapeutic seizure activity. Therefore, the client should not take benzodiazepine before ECT. C. ECT is typically prescribed 2 or 3 times a week for approximately 6 to 12 treatments total. D. Medication is the primary treatment for most clients who have depression. ECT might be the first-line treatment in specific situations such as delusional depression or if a client cannot take medications due to other medical problems.

What drugs are used in ECT therapy?

- atropine: to decreases secretions -anesthesia: to mildly sedate -Succinylcholine: muscle relaxant to decrease risk for injury

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply): 1. avoid eye contact to prevent escalation of anxiety 2. establish rapport with the client 3. identify the cause of the anxiety 4. validate the client's feelings 5. develop a flexible crisis intervention plan

-establish rapport with the client -identify the cause of the anxiety -validate the client's feelings

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take? A. Administer oxygen B. Administer an anticonvulsant C. Administer an opioid antagonist D. Administer IV fluids

A. Administer oxygen In preparation for ECT, the anesthesiologist administers succinylcholine, which paralyzes respiratory muscles. Clients require oxygen administration until their respiratory status is stable.

A nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Believes that others are deceiving him B. Desires to be the center of attention C. Views himself as inferior to others D. Demonstrates a grandiose sense of self-importance E. Persistently holds onto grudges

A. Believes that others are deceiving him E. Persistently hold onto grudges A client who has a paranoid personality disorder believes, without evidence, that others are deceiving him and worries constantly about trusting those that are close to him. A client who has histrionic personality disorder always desires to be the center of attention, has shallow expression of emotions, and demonstrates self-dramatization. A client who has avoidant personality disorder views himself as inferior to others, worries constantly about being criticized, and does not fully engage in new interpersonal relationships. A client who has narcissistic personality disorder has a grandiose sense of self-importance, lacks empathy, and has a sense of entitlement. A client who has a paranoid personality disorder persistently holds onto grudges and finds hidden demeaning meanings in benign remarks.

A nurse is assessing a client who was diagnosed with schizophrenia. Which of the following client findings is considered a positive symptom of schizophrenia? A. Hallucinations B. Social withdrawal C. Anergia D. Flat affect

A. Hallucinations Positive symptoms are grouped into the following categories: content of thought, form of thought, perception, and sense of self. The nurse should identify that hallucinations fall under the category of perception and cause the client to experience sensory perceptions that are not associated with reality. Other positive symptoms include delusions, depersonalization, and concrete thinking. Negative: Social Withdrawal, Anergia, Flat Affect

A nurse is caring for a client who has a substance use disorder and was involuntarily admitted by court order for 90 days. When the nurse attempts to administer prescribed oral lorazepam to decrease the manifestations of withdrawal, the client aggressively refuses. Which of the following actions should the nurse take? A. Place the lorazepam on hold. B. Request a prescription for IM lorazepam. C. Request that another nurse attempt to administer the lorazepam. D. Place the lorazepam in the client's food.

A. Place the lorazepam on hold. Clients who are in a health care facility due to an involuntary admission retain the right to refuse treatment, including prescribed medications. Therefore, the nurse should hold the medication, document the client's wishes in the medical record, and notify the provider of the refusal.

A nurse is assessing a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms? A. Positive B. Cognitive C. Negative D. Affective

A. Positive The nurse should identify a client who has schizophrenia and is experiencing delusions is demonstrating a positive symptom. Positive symptoms are seen early in clients who have schizophrenia and are easier to detect than other types of symptoms. Other positive symptoms can include hallucinations, disorganized speech, and disorganized behavior.

A 35-year-old - who's a divorced patent of three - was admitted 5 days ago with major depression after a suicide attempt. He was prescribed a daily dosage of fluoxetine (Prozac). Since starting the medication, his appetite and participation in group therapy have improved. Which nursing diagnosis should receive the highest priority? A. Risk for self-directed violence related to suicide attempt B. Deficient knowledge related to antidepressant therapy C. Chronic low self-esteem related to recurrent depression D. Anxiety related to disruption in role performance

A. Risk for self-directed violence related to suicide attempt Despite the improvement in appetite and group participation, the client's risk for self-inflicted harm remains a priority. When depression is resolving, the client can focus more on carrying out a suicide plan.

A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving? A. The death was a result of violence. B. The client expresses anger over the loss. C. This is the client's first experience of the loss of a family member. D. The client demonstrates reorganization of behavior

A. The death was a result of violence. When death is a result of violence, is traumatic, or is unexpected, the loss can result in maladaptive grieving for those left behind. This type of grief is complicated by the survivors not having an opportunity to prepare for the death or to say goodbye.

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms? a. Conversion b. Projection c. Undoing d. Regression

ANSWER: projection RATIONALE: projection is a defense mechanism in which the client refuses to acknowledge unacceptable personal characteristics and transfers feelings, thoughts, or traits onto another person

A nurse is obtaining a client's medical history prior to scheduling the client for electroconvulsive therapy (ECT). Which of the following findings should the nurse identify as a potential complication of the procedure? A. Severe depression B. Cardiac arrhythmia C. Bipolar disorder D. Parkinson's disease

B. Cardiac arrhythmia A client who has cardiac arrhythmia needs further evaluation since the greatest risk of death due to ECT is related to cardiac complications.

A nurse is teaching a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should inform the client that TMS can cause which of the following adverse effects? A. Retrograde amnesia B. Seizures C. Confusion D. Suicidal ideation

B. Seizures Although uncommon, seizures are a potential adverse effect of TMS.

A client states, "I just don't know what to do about my partner's drinking. Every time I see him drinking beer, I start to feel extremely anxious." Which of the following is the most therapeutic response by the nurse? A) "Tell me more about what is going on with your son. Is he still causing problems for you?" B) "At one time you told me you were drinking regularly with your partner. Are you continuing to do that?" C) "The next time your partner starts drinking, what is something you might do to decrease your anxiety?" D) "I think you should attend an Al-Anon meeting. It is a support group for people who are troubled by another person's drinking."

C) "The next time your partner starts drinking, what is something you might do to decrease your anxiety?"

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms? A. "I just feel so hopeless." B. "The government has been watching my house." C. "I am unable to remember to brush my teeth." D. "I no longer enjoy the activities I used to love." Check Answer

C. "I am unable to remember to brush my teeth." The nurse should recognize that memory impairment is a cognitive symptom of schizophrenia. Other cognitive symptoms include impaired concentration, judgment, and problem-solving.

A nurse is caring for a group of clients on a mental health unit. Which of the following should the nurse recognize as a maladaptive defense mechanism? A. A client slams a drawer after misplacing her wallet B. A man buys his partner a gift after flirting with his secretary C. A client forgets to schedule needed appointments when fearing chemotherapy D. A client ignores the thought of pain when scheduled for oral therapy

C. A client forgets to schedule needed appointments when fearing chemotherapy

What is the treatment of choice for clients with borderline personality disorder? a. Group therapy b. Behavioral therapy c. Dialectical behavior therapy d. Psychoanalytical psychotherapy

C. Dialectical Behavior Therapy - includes cognitive, behavioral, and interpersonal therapies. These are useful in the treatment of self-injurious and para-suicidal behavior, which are the characteristics of BPD. Group therapy is not appropriate because clients with BPD show destructive behaviors directed towards others and may harm others during group activities. Behavioral therapy is useful for OCD, antisocial, and avoidant personality disorders. Psychoanalytical and psychotherapy is the treatment of choice for histrionic personality disorder.

A nurse is caring for a client who begins yelling at other clients in the Day room. Which of the following actions should the nurse take? A. Tell the client she will lose television privileges if she does not calm down. B. Stand in front of the client to show her who is in control. C. Express empathy about to the client's feelings of anger. D. Place the client in restraints.

C. Express empathy about to the client's feelings of anger.

A nurse working in suicide prevention is discussing suicide interventions with a newly hired nurse. Which of the following statements indicates that the newly hired nurse understands when a tertiary intervention is needed? A. I should perform screenings to identify clients at risk for suicide B. I should recognize the lethality of the suicide plan C. I should provide counseling for the family following the suicide of client D. I should provide a safe environment to prevent the client from committing suicide

C. I should provide counseling for the family following the suicide of a client

A nurse on an inpatient mental health unit is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse's assessment priority? A. Home environments B. Support systems C. Suicide precautions D. Psychiatric history

C. Suicide precautions

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? A. Hallucinations B. Impaired memory C. Dysphoria D. Social discomfort

D. Social discomfort The absence of something that should be present is considered a negative symptom of schizophrenia. Social discomfort, the inability to enjoy activities, or a lack of goal-directed behavior are negative symptoms of schizophrenia. Positive Symptoms: Delusions, hallucinations, disorganized speech, and bizarre behaviors

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply.) Diagnosis of schizophrenia Age greater than 55 Bachelor's degree Male gender Recent marriage

Correct: Diagnosis of Schizo, Age greater than 55, Male Diagnosis of schizophrenia is correct. Psychiatric disorders, including schizophrenia, increase a client's risk for suicide. Age greater than 55 is correct. A client who is older than 55 years of age has an increased risk for suicide. Bachelor's degree is incorrect. Professionals and those who have a college education have a reduced risk for suicide. Male gender is correct. Male gender increases a client's risk for suicide. Recent marriage is incorrect. Marriage reduces a client's risk for suicide.

A nurse is assessing the suicide risk of a group of clients on a mental health unit. Which of the following clients should the nurse identify as having a risk factor for a suicide attempt? A. A client whose family visits him weekly from out of town. B. A client who usually acts impulsively. C. A pregnant female client who is at 6 months gestation. D. A client who attends religious services at the mental health facility.

D. A client who usually acts impulsively The presence of impulsive or aggressive behaviors is a risk factor for suicide. A client who is depressed and/or has suicidal ideation is more likely to attempt suicide if she also demonstrates impulsive behaviors and acts quickly without thinking. Having effective problem-solving and coping skills are both

A nurse is caring for a client who lost all his possessions in a house fire and states, "i have no idea what i am going to do. I cannot even think right now". Which of the following actions should the nurse take? A. Identify other housing options and sources of transportation B. Notify the facility chaplain to request scheduling an appointment c. Confirm that everything will be alright because belongings can be replaced d. Maintain eye contact with client and summarize the client's feelings

D. Maintain eye contact This demonstrates therapeutic communication. during the initial interview, it is important for the nurse to provide an atmosphere of support and safety. If a person believes that someone is genuinely concerned, then he may believe that help is available. Maintaining eye contact demonstrates support, empathy, and advocacy.

A nurse is planning care for a client who is scheduled to undergo electroconvulsive treatment (ECT). Which of the following interventions should the nurse include? A. Maintain a clear liquid diet for 6 to 8 hr prior to ECT B. Allow the client to sleep for 3 to 4 hr following ECT C. Administer IM epinephrine to the client prior to ECT D. Reorient the client to the environment after ECT

D. Reorient the client to the environment after ECT Due to a transient period of confusion after ECT, the nurse should plan to reorient the client following ECT.

How to set up a room for Electroconvulsive therapy (ECT)?

EEG monitor, BP monitor, cardiac monitor, O2

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take? A. Monitor the client closely to prevent self-mutilation B. Set limits to prevent exploitation of other clients C. Discourage flamboyant or seductive behaviors D. Give positive feedback when client is assertive with staff or clients

Give positive feedback when client is assertive with staff or clients The client who has dependent personality disorder has great difficulty demonstrating assertive behavior and commonly relies on others to make decisions. The nurse should encourage the client to be more assertive and independent.

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states "I'm feeling really down and don't want to talk to anyone right now." which of the following responses should the nurse make?

I'll just sit here with you for a few minutes then

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?

Identify cues in the client's behavior that might have warned them that he was contemplating suicide.

You have a patient and your assessing them for conversion disorder, what would you expect as a finding?

Involuntary loss of sensory function.

A nurse is planning care for a group of clients on a mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Provide continuity of care by assigning the same staff. Consistent interactions are important in any care setting, but especially in a mental health. This will help clients establish trust and a sense of security.

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head is down, and he is wringing his hands. Which action should the nurse take?

Remain with the client. Remaining nearby the client will help alleviate feelings of abandonment and reassures the client of his safety.

Client with new diagnosis of HIV, "I don't care what the doctor says, I don't have HIV..." type of crisis?

Situational

A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which action should the nurse take first?

Speak to the client calmly, giving simple directions. When providing care for an angry client, the nurse should first use the least restrictive intervention. Therefore, the nurse should speak to the client calmly and give her simple directions. This action might help prevent escalation of the client's angry behavior.

A nurse is caring for a client whose partner died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief? A. The client joined a bowling league 2 months ago. B. The client has kept his partner's closet untouched since her death. C. The client exercises at a local health facility 3 days each week. D. The client meets his daughter for dinner every week.

The client has kept his partner's closet untouched since her death.

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures? A. Nurses should expect clients to adapt to the care provided regardless of culture. B. Nurses should focus on clients' cultures, rather than their ethnicity, when providing care C. Nonverbal communication is important in few cultures D. Culture plays no role in determining when a client will seek medical care.

a. Nurses should focus on clients' cultures, rather than race, when providing care.

What are the functions of dialectical behavioral therapy (DBT)? Select all that apply. a. To provide alternate ways of dealing with frustration b. To enhance behavioral capabilities of the client c. To reduce the client's symptoms d. To enhance therapist capabilities and motivation e. To help the client recognize and correct inaccurate mental schemata

a. To enhance behavioral capabilities of the client (by making a note on behavior patterns exhibited by the client) b. To reduce the client's symptoms. (Many interventions specialized for the treat- ment of personality disorders, including DBT, are more often evidenced by symptom reduction rather than significant improvements in social functioning.) c. To enhance therapist capabilities and motivation (to treat clients effectively).

A nurse is providing a community health education class about suicide prevention. which of the following should the nurse identify as risk factors for suicide? a. substance use disorder b. age greater than 45 years old c. college kid d. Cat e. schizophrenia

a. substance use disorder b. age greater than 45 years old e. schizophrenia

A nurse is planning care for a client who has a personality disorder and demonstrates manipulative behavior. Which of the following interventions is appropriate to include in the plan of care? a) Allow manipulation so as to not raise the client's anxiety. b) Create a strict schedule for the client's activities to discourage manipulation. c) Institute consequences for manipulative behavior. d) Bargain with the client to discourage manipulative behavior.

c) Institute consequences for manipulative behavior