Mental Health v1-1

Hallucinations

A nurse is assisting with admission of a client who has schizophrenia. During the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia?

Ask the client to repeat what the voices are saying

A nurse is assisting with the admission of a client who reports hearing voices telling him what to do. Which of the following actions should the nurse take?

Lorazepam (Ativan)

A nurse is caring for a client who has alcohol use disorder and is experiencing with drawl psychosis. Which of the following medication should the nurse prepare to administer. Alcohol withdrawal psychosis can begin 8 to 10 hours following alcohol cessation. Benzodiazepine lorazepam can be given.

Determine if the client is in danger to herself.

A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions is a nurses priority?

ascites

A nurse is caring for a client who has cirrhosis of the liver due to alcohol use disorder. Which of the following findings should the nurse expect? Cirrhosis of the liver caused destruction of liver cells. Ascites is accumulation of serious fluid in the abdominal cavity due to portal hypertension. Jaundice weight loss and esophageal varices are other expected findings.

Would you like to talk about why you feel this way?

A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client informs the nurse, "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make?

Dreaming about the assault

A nurse is collecting data from a client who has post-traumatic stress disorder PTSD due to sexual assault that occurred three months ago. Which of the following findings should the nurse expect?

Hypertension

A nurse in an urgent care clinic is collecting data from a client reports recent cocaine use. Which of the following manifestations should the nurse expect?

Assist the client in identifying resources

A nurse is assisting a client whose house was just destroyed by a fire. Which of the following actions should the nurse take? The nurse should offer emotional support and identify resources to help the client.

Long-term nursing care Center

A home health nurse is collecting data from a client who has advanced dementia and who's caretaker recently passed. The client is not violent or suicidal. For which of the following treatment setting should the nurse recommend a referral for this client?

BUN 15 mg/dL

A nurse In a providers office is reviewing the laboratory report of a client who has bulimia nervosa. Which of the following laboratory test indicates a therapeutic response to the treatment plan? BUN 10-20 Potassium 3.5 to 5 Sodium 135 to 145 Hematocrit 42%to 52% for males 37% to 47% for females.

Post a large calendar on the bulletin board

A nurse at a long term care facility notes that a client with dementia is having problems with orientation. Which of the following actions should the nurse take to improve clients a level of orientation?

Determine the clients level of disorientation

A nurse is assisting with The admission of a client who has alcohol use disorder and is experiencing with drawl. Which of the following actions is priority for the nurse? Determine the clients level of disorientation to ensure that the client is safe from self injury or harm.

Psychodrama Groups

A nurse in an acute mental health facility is preparing in a group therapy session in which client and act realistic situations to help them process past events. The nurse should identify that which of the following types of group therapy is being carried out?

I talk to the client about making a safety plan

A nurse in an emergency department is caring for a client who states, "I tripped over the dog again." The nurse notes that the client has multiple lacerations and sees in the clients medical record that she visited two months ago for similar injuries. Which of the following actions should the nurse take?

Tell the parent that Child protective agency must be notified

A nurse in an outpatient facility is assessing a three month old infant who has lost weight and has injuries that indicate physical abuse. When preparing to interview the parent, which of the following actions should the nurse take? Inform them about Cps and explain the process to the parent.

"Suppose I just spend some time with you instead. We don't have to talk. "

A nurse in a mental health clinic is beginning a counseling session with a client who is having difficulties in a personal relationship. The client states that she does not want to talk at all today. Which of the following responses should the nurse offer? Rationale: therapeutic communication of offering self and using silence. Conveys desire to understand and help promote client self worth and that he doesn't have to behave in a specific way.

Continue to do activities that your family did before your partners absence

A nurse in a mental health clinic is working with a client whose partner recently started working overseas. The client states, "my youngest child is having difficulty coping with my partner's absence. "Which of the following responses should the nurse offer? Returning to familiar activities can help reestablish a sense of normalcy for the family.

"Tell me what you are seeing by that chair."

The nurse is collecting data from a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make?

That must be very frightening

A nurse is caring for a client reports that the television set and her room is really a two way radio and states, " voices are coming from the TV, and everything we say in the room is being recorded. "Which of the following responses should the nurse make?

Talk to the client from two arm lengths away

A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take?

Put the client's mattress on the floor

A nurse is caring for a client who has a neurocognitive disorder and wanders at night. Which of the following actions should the nurse take to promote clients safety

Speak to the client using simple and concrete terminology

A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client?

Naltrexone (ReVia)

A nurse is assisting with planning care for a client who has completed detoxification from opioid abuse disorder. The nurse should plan to teach about which of the following medications? Naltrexone is an opioid antagonist that is used for long term maintenance of opioid use disorder.

Denial

A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect from the client?

Sedation

A nurse is preparing to administer a benzodiazepine to a client who has generalized anxiety disorder. The nurse should tell the client to expect which of the following adverse effects?

Fluoxetine (Prozac)

A nurse on a mental health unit is preparing to discharge a client who has bulimia nervosa. Which of the following medication should the nurse expect the provider to prescribe the client? Fluoxetine is an SSRI used for depression and bulimia to reduce the cravings of carbohydrates for the treatment of binge eating. The dose for bulimia is three times higher than the dose for depression.

rhinorrhea (runny nose)

A nurse on an inpatient mental health unit is assessing a client who has a history of opioid use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect? Opioid withdrawal symptoms are rhinorrhea, lacrimation, pupillary dilation, yawning, Piloerection.

Facilitate change in the clients behavior

The nurse is preparing to meet with a client who has borderline personality disorder. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship?

Paying attention to body language

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the proper use of active listening?

Taper the medication gradually over several weeks

A nurse is contributing to the plan of care for a client who has physical dependence on alprazolam and must discontinue the medication. Which of the following actions should the nurse recommend?

Encourage the client to have frequent rest periods

A nurse is contributing to the plan of care for a client with bipolar disorder who has acute mania. Which of the following intervention should the nurse recommend including in the plan? Rationale: The client is at risk for exhaustion when having acute mania.

Offer high-calorie beverages To a client who is in the manic phase of bipolar disorder

A nurse is contributing to the plan of care for a group of clients. Which of the following interventions is priority for the nurse to include?

Maintain close observation of the client

A nurse is planning care for a client who has Borderline Personality Disorder who self-mutilates which of the following treatment approcahes should the nurse plan the take?. Maintaining close observation reduces risk of injury

"I don't see anyone, but it sounds like you are frightened. "

A nurse is interacting with a client who has a psychotic disorder when the client suddenly turns her head as if listening to some thing and says, the boss says she is going to hit me with a stick! "Which of the following responses should the nurse offer?

The client is experiencing mild acetaldehyde syndrome

A nurse is collecting data from a client who is receiving Disulfiram for alcohol adveración therapy. The client is experiencing palpitation and reports nausea, a headache, and extreme thirst. The nurse should identify which of the following situations occurring? when alcohol consumption is combined with this medication as little as 7ml of alcohol can cause this

Xerostomia (dry mouth)

A nurse is collecting data from a client who is taking buspirone to treat generalized anxiety disorder. Which of the following findings should the nurse identify as an adverse effect of this medication. Buspirone can cause Xerostomia (dry mouth), headaches, nausea, and insomnia.

Blurry vision

A nurse is collecting data from a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2. Which of the following findings should the nurse expect? LithiumToxic levels are 2-2.5 including blurry vision, ataxia, colonic twitching, severe hypotension, and polyuria.

Hallucinations

A nurse is collecting data from a client who was diagnosed with schizophrenia. The nurse should identify that which of the following findings is considered a positive symptoms of schizophrenia.

Giving away possessions

A nurse is collecting data from a client who was recently admitted following a suicide attempt. Which of the following behaviors is priority for the nurse to report to the adolescent treatment team? Giving away possessions indicates that this client is at great risk for suicide.

Difficulty sleeping for several weeks Inability to concentrate on simple task Not bathing for several days Lack of enjoyment from a long-time hobby of gardening

A nurse is collecting data from a client who was recently admitted for a treatment of major depressive disorder MMD. Which of the following findings should the nurse expect the client to report? Select all that apply

Sedation

A nurse is collecting data from a school age child who has ADHD and has been taking Desiparmime, which of the following adverse effects should the nurse except the child's parents to report? Tricyclic antidepressants can cause sedation along with other anti-cholinergic effects.

Request for a prescription for chlordiazpoxide

A nurse at an acute care facility is assisting with the care of a client who is receiving IV antibiotic regimen for an infection. The client reported daily alcohol use at home. On the second day of admission, the client becomes agitated, hypertensive, and tachycardic. Which of the following actions should the nurse plan to take. Chlordiazpoxide is an anxiolytics benzodiazepine prescribed for alcohol withdrawal reducing manifestation preventing seizures and delirium.

Identify professional boundaries during the initial interaction

A nurse in a mental health facility is planning to promote the development of therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take?

Encourage reality testing

A nurse is planning care for a client who has disassociative disorder and is experiencing flashbacks while in public. Which of the following intervention should the nurse include in the plan to help the client recognize and counter the flashbacks? Reality testing: scanning the surrounding to see if others are afraid and re-oriented to time and place.

maintain adequate hydration

A nurse is planning care for a newly admitted client who has Bipolar Disorder and is experiencing Acute Mania. Which of the following client goals should the nurse identify as priority? The goal is to prevent physical exhaustion and meet nutritional needs: consider Maslow's hierarchy of needs

orientation phase

A nurse is planning to work with a client who developed a set of goals. During which of the following phases of the therapeutic relationship should The nurse complete this task? Orientation phase: establish rapport and boundaries develop goals, plan of action and discuss confidentiality.

Maintain an open posture

A nurse is preparing to interview a client who has generalized anxiety disorder. Which of the following actions should the nurse take? Nurses should be mindful of nonverbal cues such as eye contact, facial expressions, and posture. Maintain an open posture and do not cross arms.

Swiss cheese

A nurse is reinforcing dietary teaching with a client who has a new prescription for phenelzine, a monoamine oxidase inhibitor MAOI. The nurse should recognize that which of the following foods interact with this medication? How many cheeses are high in tyramine and should be avoided when using MAOIs

"You will slowly be exposed to increasing levels of public spaces. "

A nurse is reinforcing teaching with a client who has agoraphobia about systemic desensitization. Which of the following comments should the nurse include in teaching?

This medication should not be stopped abruptly

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and has a new prescription for venlafaxine. Which of the following statements should the nurse make?

You can expect to wake up 15 minutes after the procedure.

A nurse is reinforcing teaching with a client who has major depressive disorder and is scheduled to begin electro convulsive therapy ECT. Which of the following pieces of information should the nurse include? ECT: do not give benzodiazepine before ECT, two or three times a week for approximately 6 to 12 month treatment total, medication is the primary treatment.

My partner might begin to shake

A nurse is reinforcing teaching with the partner of a client who is at risk for alcohol withdrawal after six hours of cessation. Which of the following statements by the partner indicates an understanding of the teaching?

Help the client deal with a distorted thought process

A nurse is reviewing the plan of care for a client who has bipolar disorder which of the following is an effect of using cognitive behavioral therapy CBT for a client who has bipolar disorder?

Talk to the client about available community resources.

A nurse is speaking with a client whose partner was killed unexpectedly. The client states, "I just don't know what to do now. "Which of the following actions should the nurse take?

"It sounds like you are concerned about your family's reaction."

A nurse is talking with a client about his admission to a mental health unit. The client states, "I just don't know if I should be here. What will my family think?" Which of the following responses by the nurse uses the therapeutic technique of reflection.?

We have a professional relationship, not a personal relationship.

A nurse on a mental health unit is caring for a client who asked the nurse out to dinner. Which of the following responses should the nurse provide?

I can play the flute while wearing a suit. You are cute.

A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association? Neologisms are made up words Word salads or random words mixed together. Associative looseness " my friend is a joint my joint aches"

Memamtine (Namenda)

A nurse in a providers office is collecting data for a client who has been taking donepezil for Alzheimer's disease. The data indicated that the clients disease is progressing and becoming more severe. Which of the following medication should the nurse expect the provider to prescribe?

Disulfiram (Antabuse)

A nurse in a rehabilitation unit is discharging a client who has alcohol use disorder. Which of the following prescription should the nurse anticipate for the client? Disulfiram is in medication A form of aversion therapy.

Opiates

A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has substance use disorder for which of the following substances?

Protect the Client From Impulsive Behavior.

A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurses priority?

Amenorrhea (absence of menstruation)

A nurse is assisting with the collection of admission data for a client who has anorexia nervosa. The client has lost 11.4 kg 25 pounds over the past month and currently Weighs 38.6 kg 85 pounds. The nurse should expect which of the following findings? Anorexia nervosa: cold extremities, yellow skin, hypercarotenmia, hypokalemia, and constipation.

Ask the client what the voices are saying?

A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions is the nurses priority?

Approach the client and a non-threatening manner

A nurse is caring for a client who has schizophrenia. The nurse notices the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse take first? Least restrictive interventions creating a non threatening environment. Physical or chemical restraints are only used when safety of the clients, staff or others is at risk.

Informing the client that an injection will be administered if the client remains agitated

A nurse is caring for a client who is receiving care at an inpatient alcohol treatment facility. Which of the following actions should the nurse identify as an example of an intentional tort? This is an example of assault. Assault is an intentional tort. A threat to harm.

"What did you learn from your marriage to help you in the future?"

A nurse is caring for a client who is receiving cognitive behavioral therapy. The client tells the nurse, "nothing good ever happened to me during my marriage. "When using cognitive reframing, which of the following responses should the nurse provide? Cognitive reframing Turning negative perceived situations and developing more accurate and positive perceptions.

presence of lanugo

A nurse is caring for a client with anorexia nervosa who has tight skin. Which of the following findings should the nurse expect? Laguno is fine neonatal like hair growth on the body as a result of malnutrition and starvation

The client is unable to express pleasure

A nurse is collecting data from a client who Lost his mother a few months ago and is feeling depressed. Which of the following findings should cause the nurse expect the client has prior major depressive disorder? MMD signs and symptoms: inability to express pleasure, Decreased energy depressed mood for most of the day, thoughts of death, being self-critical, and inappropriate guilt.

I could have done something to prevent my cousins death

A nurse is collecting data from a client who has adjustment disorder which of the following statements by the client should the nurse recognize as a manifestation of this disorder? Adjustment disorder In response to a stressful events can include guilt depression anxiety and anger. Social withdrawal or work or academic changes can be treated with anti-depressants.

restlessness

A nurse is collecting data from a client who has generalized anxiety disorder GAD. Which of the following findings should the nurse expect.?

"I consider myself a good problem solver "

A nurse is collecting data from a client who has major depressive disorder regarding suicide risk factors and protective factors. Which of the following statements should the nurse identify as a protective factor that decreases the clients risk for suicide?

Ignoring unit rules

A nurse is collecting data from a client who has oppositional defiant disorder. Which of the following findings should the nurse expect?

impaired recent memory

A nurse is collecting data from a client who is at risk for cognitive impairment. Which of the findings should the nurse identify as an early indication of cognitive decline. Short term memory loss is generally an early indicator of mild cognitive decline. Also misplaying household items and demonstrating subtle changes im personality.

"I only got shoved a little bit, and it was my fault for coming home late. "

A nurse is interviewing a client who is seeking help for intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension building phase of the cycle of violence?

Determine which stage of grief the client is experiencing

A nurse is planning care for a client who is experiencing complicated grief following the unexpected death of his partner. Which of the following actions should the nurse plan to take first? Assess first (collect data)