Mental Health Final
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?
"Come with me to an area where we can talk without interruption."
A nurse is providing teaching for a client who has a new prescription for clozapine. Which of the following statements indicates the client understands the teaching?
"I will rise slowly from a lying position to prevent fainting while taking this medication"
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
"It sounds like you're having a difficult time."
A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?
"What are the voices telling you to do?"
A nurse anticipates positive symptoms to include
-Hallucinations -Aggression -Disorganized thinking
A nurse is caring for a patient who has bipolar 2. Which of the following behaviors by the client should the nurse interpret as displaying hypo mania behavior? (Select all that apply.)
-Inflated self-esteem -Distractable -Rapid shift of thought
A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)
-Interacting with others in a flirtatious way -Talking in rapid, continuous speech -Spending large sums of money
Schizoaffective is best defined as affective disorder that may include:
-Mania -Bipolar Depression -Mixed
A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.)
-Muscle spasms of the neck -Tremors of the hands -Fidgeting behavior
A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (Select all that apply.)
-Paroxetine -Carbamazepine -Valproate -Lithium
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)
-Tongue thrusting and lip smacking -Facial grimacing and eye blinking -Involuntary pelvic rocking and hip thrusting movments
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
Administer the morning dose of lithium.
A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?
Check the client's mouth after the client takes medication.
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?
Dysrhythmias
A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effects of haloperidol?
Extrapyramidal symptoms
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
Flat affect
A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings is this client exhibiting?
Grandiosity
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take FIRST?
Inspect the cuts for debris.
A nurse is assessing a client who has schizophrenia. Which of the following behaviors should the nurse anticipate?
Invents words that have no meaning
A nurse is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse plan to take?
Investigate what situations precipitate anxiety.
A nurse determines the best approach in caring for clients who are aggressive or violent?
Knowing where colleagues are and making sure that they know where you are
A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take? Correct!
Limit the number of questions asked during assessments
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?
Liver function tests must be monitored
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?
Major depressive disorder
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?
Remain with the client for a while.
A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?
Significant change in weight
A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?
Sit with the client and offer simple, direct information.
A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?
Sit with the client during meals and snacks
The nurse understand when communicating with a patient, which of the following would the nurse use to convey positive body language?
Sitting at the patient's eye level
A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing?
Situational
A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect?
Sleep distubances
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take?
Speak slowly in a low, calm voice
A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?
The family's religious practices
A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following?
The lithium level is at a toxic level
Schizophrenia main problem is increased level of dopamine in the client's brain
True
A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
Twisting tongue movements
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?
Walk with the client at a gradually slower pace.
Neologism
words that only have meaning to the individual using the term
A nurse is assessing a client who has bipolar disorder and has just started taking aripiprazole one month ago. The nurse should notify the provider of which of the following findings?
Muscle stiffness
A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse correctly recognizes the client's use of the word flakala as an example of which of the following alterations in speech?
Neologism
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
Neuroleptic malignant syndrome
Word salad
Patient use of real words spoken in a sequence so that the words have no logical meaning with one another
Which theorist introduced the concept of the nurse-client relationship?
Peplau
A nurse responds to a patient's statement with silence based on the rationale that this technique is used primarily to do which of the following?
Permit the patient to gather his or her thoughts
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
Plan the client's schedule to allow time for rituals.
A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates an understanding of the teaching?
"I will attend psychotherapy to help manage my depression."
A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?
"Clients who are involuntarily admitted have the right to informed consent."
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing exercise in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?
"Come with me. Here is a milkshake to drink"
A nurse is caring for an patient who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
"I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
A client becomes very upset and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make?
"I care about you, and I am concerned that you feel so sad."
During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?
"I don't care about work anymore since I was not given a promotion."
A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective?
"I fix myself a pot of coffee when I get anxious."
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
"I plan to sit on a park bench for a few minutes each day."
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 nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?
"I'll stay with you a few minutes."
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?
"In my dreams, all I can see are the wounded reaching out and trying to grab me."
A nurse is reading the medical record for a client who has schizophrenia which indicates that the client exhibits depersonalization. Which of the following statements by the client confirms that she is experiencing depersonalization?
"My hands and feet are smaller than they used to be"
A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?
"Tell me what is concerning you."
A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"The courts might require me to discuss confidential information."
A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make?
"The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss."
A nurse is teaching male client who has a depressive disorder about sertraline. Which of the following information should the nurse include in the teaching?
"This medication may cause an inability to orgasm."
A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make?
"We will call your family in time for them to get here."
A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?
"You may experience a decreased sex drive while taking this medication."
A nurse is providing teaching to a client who has bipolar disorder and is to begin taking haloperidol. Which of the following information should the nurse include in the teaching?
"You may experience dizziness upon standing while taking this medication."
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
"You must be very upset about something."
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take?
"You must feel very concerned and disappointed by that information"
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?
"You seem to be having very frightening thoughts."
A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse take prior to the scheduled ECT? (Select all that apply.)
-Check the client's blood pressure -Witness the informed consent -Request and ECG
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).
-Establish rapport with the client -Identify the cause of the anxiety -Validate the client's feelings
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)
-Facial grimacing and eye blinking -Involuntary pelvic rocking and hip thrusting movements -Tongue thrusting and lip smacking
A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.)
-Fidgeting behavior -Tremors of the hands -Muscle spasms of the neck
A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.)
-Know the layout of the facility. -Avoid wearing necklaces during client care. -Provide immediate verbal feedback for escalating behavior.
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.)
-Male gender -Diagnosis of schizoaffective -Age greater than 55
A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?
A client who has a WBC of 2,900 cells/mm3
A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?
A client who has been taking amitriptyline for 3 months for depression
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
A private room in a quiet location on the unit
A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
An adult client following a suicide attempt
A nurse is caring for a group of clients in an acute mental health facility. Which of the following clients has the legal right to refuse treatment?
An older adult client who was voluntarily admitted
A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?
Carbamazepine
When assessing a client's potential for aggression and violence, which factor should the nurse identify as the most important predictor?
Client's history of anger
Echolalia
Constant repeating of what another person is saying
A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take?
Determine the client's need for assistance with grooming
A group of nursing students is reviewing information about Freud's personality structure. The students demonstrate understanding of this information when they identify the ability to form mutually satisfying relationships as a function of which of the following?
Ego
A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?
Explain that antidepressants often take several weeks to be fully effective.
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?
Express empathy about the client's feelings of anger
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?
Express empathy about to the client's feelings of anger.
A nurse recognize females select more lethal methods to commit suicide
False
Self-awareness is achieved primarily from feedback from others.
False
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.
A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?
Increase your fluid and fiber intake to prevent constipation
A nurse is caring for a major depressed patient who failed an examination in school the week before. The student spends the group session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?
Projection
Clang association
Pt use of words that rhyme
A nurse is caring for a client who is hospitalized for mental health treatment. Which of the following nursing approaches is therapeutic to include in the client's plan of care?
Spending time sitting with the client
A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?
Talk to the client and identify the specific limits that are required of the client's behavior.
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hr hold is over for which of the following conditions?
The client is a danger to herself or others
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
The client runs 4 miles outdoors every afternoon.
A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?
The client's behavior has become impulsive in the past few weeks
A nurse recognizes the purpose of the defense mechanism for patients
To protect the ego from anxious feelings, including guilt
A nurse is caring for a patient receiving Amitriptyline the nurse understands this medications is
Tricyclic
A patient is currently taking paroxetine and start taking St. John Wort. The nurse recognize the patient is now at high risk for developing Serotonin syndrome
True
Mental health recovery is the single most important goal for the mental health delivery system.
True
To be considered healthy, a person also must be mentally healthy.
True
A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect?
Viral infection
A nurse is assessing a client who has bipolar disorder and is taking risperidone. Which of the following findings should the nurse expect?
Weight gain
A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
You should try to see your partner's point of view before your own."
A nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make?
"I see that you have on clean clothes and have combed your hair."
A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?
"I understand that you are angry. However, I followed the appropriate protocol."
A nurse recognize usually, there are precursors to aggression and violence. Which behaviors indicate an impending aggressive episode? (Select all that apply.)
-Pacing -Anxious -Raised tone and volume
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
-Perfectionist behavior -Rule-conscious behavior -Difficulty relaxing
A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?
Anhedonia
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?
Assign a staff member to stay with the client at all times.
A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse implement to establish therapeutic relationships with the clients?
Control the pace of establishing the nurse-client relationships.???
A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?
Monitor for risk of self-harm
A nurse is caring for a aggressive major depressed patient experiencing anhedonia and states he saw demons in his room. The nurse recognize the patient is experiencing.
Positive and negative symptoms
A nurse admits a patient with major depressive disorders hearing voices to harm herself and others. The recognize the patient is displaying.
Positive symptoms
A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action?
Preventing self-directed violence
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
Which technique used by mental health nurses would be least effective in promoting therapeutic communication?
Reassurance
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?
Regression
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is anxious. Which of the following actions should the nurse take?
Remain with the client
A nurse is caring for a client who begins to yell and scream at staff members. Which of the following should be the nurse's priority action?
Say to the client, "I can tell that you are upset."
A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?
Self-destructive behavior despite alternative interventions
A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
Set behavioral limits for the client
A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
Set limits on the client's behavior and be consistent in approach.
