Mental Health questions and rationales

Haloperidol - Anticipated Hold next dose of buspirone - Contraindicated Request change of diet - nonessential Request prescription for digoxin - contraindicated Calmly approach client - anticipated

For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

- Cognitive awareness - Blood pressure - Sleep/wake cycle is correct - I&O - Temperature

Which of the following findings should the nurse report to the provider immediately? Select the 5 findings that require immediate follow-up.

Suggest forming a weekly support group for parents who have experienced the death of a child.

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

"I will update the plan of care as a client's manifestations of depression change."

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will talk about my feelings with a close friend."

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching?

"It is important for our child to have regular dental checkups."

A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness?

Inability to sleep

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider?

Identify the client's trigger foods.

A nurse is updating the plan of care for a client who had bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan?

"It appears as though you would like to open the door."

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make?

Blood pressure 154/96 mm Hg

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

Spending adequate time with a client who is verbally abusive

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?

Call for a team of staff members to help with the situation.

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?

A client who is experiencing delusions of persecution

A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

"Clients who are admitted involuntarily maintain the right to give informed consent for procedures."

A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make?

Move the client who has bipolar disorder to a private room.

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate neve sleeps and keeps me up, too." Which of the following actions should the nurse take?

Greater risk of attempting suicide as affect and energy improve

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect?

Use a screening tool to evaluate the client for depression.

A nurse at a provider's office is interviewing an older adult client. Which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Guided Imagery

A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members?

Stay with a client who has anorexia nervosa for 1 hr after mealtimes.

A nurse in a mental health clinic is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Command Hallucinations

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others?

An older adult client who is bedbound and has a stage IV pressure ulcer

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse?

Phenylephrine

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction?

The client has COPD

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?

Tooth Erosion

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?

- Fever - Hospital Environment - Client's age - Postoperative

A nurse is assessing a client who is displaying manifestations of delirium. Which of the following information from the client's medical record are risk factors for delirium? (Select all that apply.)

Older children who are responsible for their younger siblings

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?

"I am going to order a wheelchair for when I'm unable to walk."

A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness?

Reduce environmental stimuli

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?

Tachycardia

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?

"I'll stay with you just in case you want to talk."

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make?

Identify signs of escalation of violence.

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?

- Heart Rate - BMI - Potassium - Skin temperature - Sodium - Bowel Movement - BUN

A nurse is evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's condition? (Select all that apply.)

"Let's talk about what is upsetting you."

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make?

Permit the client to preform daily rituals to decrease anxiety.

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care.

A 35-year-old client who has major depressive disorder

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent?

Renew the prescription for the client every 4 hr.

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?

The client should obtain a sponsor before discharge for an increased chance of recovery.

A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?

Language delay

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

Easily distracted

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes for confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?

Inform the client that this admission is confidential

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first?

Mild

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

Nonmaleficence

A nurse is planning care for a client who has made repeated physical treats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation?

Assertive community treatment

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdiscplinary services for the client at home?

Establish screening programs to identify at-risk clients.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

1.5 mL

A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

- Occupational Therapy - Meal delivery services - Physical Therapy - Home Health services

A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.)

"I will not take charge of my partner's work responsibilities."

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?

A client who is taking clozapine and reports a sore throat and chills

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse plan to see first?

WBC count 2,500/mm3

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine?

Acute dystonia

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects?

Restraints - Contraindicated Urinalysis with culture - Anticipated Insert Indwelling catheter - Contraindicated Melatonin - Anticipated MRI - Nonessential IV FLuids - Anticipated

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Systematic desensitization - OCD Validation therapy - Dementia Dialectical Behavior Therapy - Borderline personality disorder Donepezil - Dementia Fluoxetine - OCD & Borderline personality disorder

For each potential provider's prescription, click to specify if the prescribed therapy is expected with obsessive compulsive disorder, dementia, or borderline personality disorder. Each therapy can support more than one disease process. `

- Stealing money from family to cover credit card charges - married multiple times - Physical altercations - Hypertextualization - Incidences of self-injury - Anxious if left alone

Select the 6 findings found in the client's medical record that are manifestations of the client's diagnosed personality disorder.

1. Violent Behavior 2. Increased agitation

The client is at risk for developing ______ as evidenced by the client's ______.

Client attempts to bit nursing staff - Condition has declined Client follows instructions - Condition has improved Client staff is silent - Condition has not changed Client verbalizes precipitating factors - condition has improved

The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not changed, or has declined.

- Offer the client warm milk at bedtime - Approach the client from the front and speak slowly - Maintain a low-stimulation environment for the client

The nurse is caring for the client. Which of the following actions should the nurse take for this client? (Select all that apply.)

- Maintain continuous observation of the client - Conduct debriefing with the client and other staff

The nurse is caring for the client. Which of the following actions should the nurse take? (Select all that apply.)

Sleep/wake cycle - no change vital signs - improvement Daytime orientation - improvement Glucose - no change I&O - improvement Pain Level - improvement Ambulation - decline in condition

The nurse is evaluating the client's response to treatments. For each assessment finding, click to specify if the finding is an improvement, no change, or a decline in the client's condition.

The nurse should first 1. Initiate IV fluids, followed by 2. administering acetaminophen.

The nurse is planning care for the client who has delirium and new prescriptions. Complete the following sentence by using the lists of options.

- "You should seek help if you have thoughts of self-harm." - "A support group might be helpful to you during this time." - "It is common for people who survived a traumatic event to experience feelings of anxiety."

The nurse is providing teaching to the client. Which of the following statements should the nurse include in the teaching? (Select all that apply.)