Mental Health Midterm/Final

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? A. "Do you feel afraid that people are trying to hurt you?" B. "What makes you think the guards were sent to hurt you?" C. "The guards are not out to kill you." D. "I don't believe this is true."

A. "Do you feel afraid that people are trying to hurt you?"

When discussing her husband, a client shares that "I would be better off alone. At least I would be able to come and go as I please and not have to be interrogated all the time." What therapeutic communication technique is the nurse using when responding, "Are you saying that things would be better if you left your husband?" A. Clarification B. Restating C. Focusing D. Reflection

A. Clarification

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? A. Platelet count B. Blood urea nitrogen C. White blood cell count D. Cholesterol level

A. Platelet count

The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? A. Somatization disorder B. Depression C. Obsessive-compulsive disorder D. Schizophrenia

A. Somatization disorder

The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? A. The client grimaced during the entire therapy session that focused on finding one's personal joy. B. The client demonstrated minimal response to the news that his discharge had been postponed. C. During the entire family visit, the client presented with an expressionless, blank look. D. During grief therapy, the client was observed laughing while another client described the death of a parent.

C. During the entire family visit, the client presented with an expressionless, blank look.

The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal? A. Decreased heart rate and blood pressure, and dry nose, mouth, and skin B. Staggering gait, slurred speech, and violent outbursts C. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis D. Constipation, insomnia, and hallucinations

C. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis

During a therapeutic encounter the nurse remarks to a client, "I noticed anger in your voice when you spoke of your father. Tell me about that." What communication techniques is the nurse using? A. Presenting reality and encouraging planning B. Giving information and encouraging evaluation C. Reflecting and exploring D. Clarifying and suggesting collaboration

C. Reflecting and exploring

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. A. Have the client state the consequences for behaving in ways that are viewed as unacceptable. B. Follow through about the consequences of behavior in a non punitive manner. C. Ensure that the client knows that he or she is not in charge of the nursing unit. D. Enforce rules by informing the client that he or she will not be allowed to attend therapy groups. E. Assist the client in identifying ways of setting limits on personal behaviors. F. Communicate expected behaviors to the client.

A. Have the client state the consequences for behaving in ways that are viewed as unacceptable. B. Follow through about the consequences of behavior in a non punitive manner. E. Assist the client in identifying ways of setting limits on personal behaviors. F. Communicate expected behaviors to the client.

Which side effects of lithium can be expected at toxic levels? Select all that apply. A. Polyuria B. Hypotension C. EKG changes D. Ataxia E. Nausea

B. Hypotension C. EKG changes D. Ataxia

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? A. Tell the client that this is not true and that we all have a purpose in life. B. Identify recent behaviors or accomplishments that demonstrate the client's skills. C. Reassure the client that things will get better. D. Remain with the client and sit in silence; this will encourage the client to verbalize feelings

B. Identify recent behaviors or accomplishments that demonstrate the client's skills.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? A. Incessant talking and sexual innuendoes B. Outlandish behaviors and inappropriate dress C. Nonstop physical activity and poor nutritional intake D. Grandiose delusions and poor concentration

C. Nonstop physical activity and poor nutritional intake

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? A. Basketball B. Ping pong C. Chess D. Writing

D. Writing

A client prescribed a selective serotonin reuptake inhibitor mentions taking the medication along with the St. John's wort daily. The nurse should provide the client with what information regarding this practice? A. Advise client to drink several glasses a day B. This will help the SSRI work faster. C. Explain the high possibilty of an adverse reaction D. Agrreeing that this will help the client remember medications.

C. Explain the high possibilty of an adverse reaction

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse addresses the spouse's concerns? A. "You seem to have a good grip on this situation. You probably should get out." B. "What aspects of this situation are the most difficult for you?" C. "What would your spouse think about your decision?" D. "This is not a good time to make that decision."

B. "What aspects of this situation are the most difficult for you?"

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? A. "Who is available to help you?" B. "What leads you to seek help now?" C. "What do you usually do to feel better?" D. "With whom do you live?"

B. "What leads you to seek help now?"

A bipolar client tells the nurse, "I have the finest tenor voice in the world. The three tenors who do all those TV concerts are going to retire because they can't compete with me." What term should the nurse use to identify this behavior? A. Grandiosity B. Limit testing C. Distractibility D. Flight of ideas

A. Grandiosity

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? A. Lack of ability to cope effectively B. Disturbances in thoughts and ideas C. Anxiety D. Unrealistic outlook

A. Lack of ability to cope effectively

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. A. Providing acknowledgment and feedback B. Giving advice and approval or disapproval C. Asking the client "Why?" D. Listening E. Maintaining neutral responses F. Restating

A. Providing acknowledgment and feedback D. Listening E. Maintaining neutral responses F. Restating

Providing care to a client diagnosed with a somatization disorder can be frustrating owing to the client's lack of an organic illness. In order to best manage this barrier to care the staff should implement which personal intervention? A. Regularly discuss their feelings about the client during the unit's interprofessional care meetings. B. Rotate care of the client among the entire nursing department staff to minimize the frustration. C. Provide a unified approach to the client's behavior so as to manage and lessen the barrier itself. D. Attend in-services that focus on the various aspects of somatic disorders.

A. Regularly discuss their feelings about the client during the unit's interprofessional care meetings.

The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. A. Remove dentures and contact lenses. B. Administer tap water enemas. C. Avoid discussing the procedure. D. Obtain an informed consent. E. Withhold food and fluids for 6 hours. F. Have the client void.

A. Remove dentures and contact lenses. D. Obtain an informed consent. E. Withhold food and fluids for 6 hours. F. Have the client void.

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. A. Provide stimulation in the environment. B. Address hallucinations therapeutically. C. Provide reality orientation as appropriate. D. Maintain NPO (nothing by mouth) status. E. Provide a safe environment. F. Monitor vital signs.

B. Address hallucinations therapeutically. C. Provide reality orientation as appropriate. E. Provide a safe environment. F. Monitor vital signs.

A client hospitalized with anorexia nervosa has a weight that is 65% of normal. For this client, what is a realistic short-term goal for the first week of hospitalization regarding the physical impact of his/her weight? A. Develop a pattern of normal eating behavior. B. Discuss fears and feelings about gaining weight. C. Verbalize awareness of the sensation of hunger. D. Gain a maximum of 3 lb.

D. Gain a maximum of 3 lb.

A client's daughter states, "My mother lives with me since my dad died 6 months ago. For the past couple of months, every time I need to leave the house for work or anything else, Mom becomes extremely anxious and cries that something terrible is going to happen to me. She seems OK except for these times, but it's affecting my ability to go to work." This information supports that the client may be experiencing which anxiety-related disorder? A. Agoraphobia B. Adult separation anxiety disorder C. Social anxiety disorder D. Panic disorder

B. Adult separation anxiety disorder

A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." What is the best initial approach to managing this behavior? A. Reprimand the client by stating, "What an offensive thing to suggest!" B. Distracting the client by suggesting, "It's time to work on your art project." C. Clarifying the nurse-client relationship by stating, "I don't have sex with clients." D. Enforcing consequences by responding, "Let's walk down to the seclusion room."

B. Distracting the client by suggesting, "It's time to work on your art project."

Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply. A. Pupillary response B. Electrolyte levels C. Elimination patterns D. Intake and output E. Exercise patterns F. Deep tendon reflexes

B. Electrolyte levels C. Elimination patterns

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? A. Stupor, lethargy, muscular rigidity B. Hypertension, changes in level of consciousness, hallucinations C. Hypotension, coarse hand tremors, lethargy D. Hypotension, ataxia, hunger

B. Hypertension, changes in level of consciousness, hallucinations

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention should the nurse include in the plan? A. Suggesting a reduction of medication B. Allowing increased "in-room" activities C. Increasing the level of suicide precautions D. Allowing the client off-unit privileges as needed

C. Increasing the level of suicide precautions

When educating a client diagnosed with bulimia nervosa about the medication fluoxetine, the nurse should include what information about this medication? A. There are a variety of medications to prescribe if fluoxetine proves to be ineffective. B. Long-term management of symptoms is best achieved with tricyclic antidepressants. C. It will be prescribed at a higher than typical dose. D. It will reduce the need for cognitive therapy.

C. It will be prescribed at a higher than typical dose.

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? A. Normal behavior B. Regression as the client is moving toward the community C. Indicative of the client's ambivalence about hospital discharge D. Evidence of the client's disturbed body image

D. Evidence of the client's disturbed body image

The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal? A. Increased appetite, irritability, anxiety, restlessness, and altered concentration B. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor C. Depression, high drug craving, fatigue, altered sleep patterns, hypertension, agitation, and paranoia D. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis

D. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis