Midterm MH

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan? A. "I can remember when my hallucinations first began." B. "I know which of my hallucinations trigger a relapse." C. "I record the number of hallucinations I have each day." D. "I will read as much information as I can about schizophrenia."

B. "I know which of my hallucinations trigger a relapse."

A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling, "You are all making fun of me." Which of the following behaviors is this client displaying? A. Grandeur B. Flight of ideas C. Erotomania D. Ideas of reference

D. Ideas of reference Rationale: Ideas of reference occur when a client believes that conversations of others always concern him and that others are ridiculing him.

A nurse is caring for a client who has been taking valproic acid. Which of the following is an expected outcome of the medication?

D. The client has decreased euphoric mood( prevents relapse of mania & depressive episodes, useful for pt's who have mixed mania & rapid cycling bipolar disorder)

A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse's priority?

HIGH FEVER

A nurse is preparing to administer the monthly injection of haloperidol decanoate to a client who has schizophrenia. Which of the following action should the nurse plan to take?

Have the client lie down for 30 min after the medication is injected.

A nurse is planning to administer olanzapine 10 mg IM to a client who has schizophrenia. Which of the following actions should the nurse take?

Monitor the client for at least 3 hr after the injection.

A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching?

This medication is given to help with extrapyramidal side effects."

A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings should the nurse expect?

Weight gain

A nurse overhears a client saying, "I am a spy, a spy for the FBI. I am an I, an eye for an eye, an eye in the sky. Sky is up high. The nurse should document the client's statement as which of the following speech alterations?

a. Clang association Meaningless rhyming of words, often forceful, such as, "Oh fox, box, and lox."

A nurse is providing teaching for a client who has schizophrenia and a new prescription for fluphenazine. Which of the following information should the nurse provide?

"Sleepiness should subside within a week."

A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings should the nurse expect? A. Weight gain B. Dependent edema C. Nightmares D. Bradycardia

A. Weight gain

a nurse is caring for a pt taking ziprasidone. the pt reports difficulty swallowing and becomes agitated with injectable admin.the nurse should contact the provider to discuss a change to which of the following meds

Aripiprazole Clozapine Asenapine

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.) A. Urinary retention and constipation B. Tongue thrusting and lip smacking C. Fine hand tremors and pill rolling D. Facial grimacing and eye blinking E. Involuntary pelvic rocking and hip thrusting movements

B. Tongue thrusting and lip smacking D. Facial grimacing and eye blinking E. Involuntary pelvic rocking and hip thrusting movements

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client? A. Watching a video with a group in the day room B. Walking with the nurse in the courtyard C. Participating in a basketball game in the gym D. Joining a group discussion about a local election

B. Walking with the nurse in the courtyard Rationale: Clients who have bipolar disorder are prone to hyperactivity. The nurse should provide activities that provide a way for the client to release physical energy, while avoiding situations that might provoke the client. In addition, walking with the nurse provides an opportunity for therapeutic communication.

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? A. "I have broken off all my past relationships because my friends and family are trying to kill me." B. "I hear voices telling me that I have been bad." C. "My hands and feet are much smaller than they used to be." D. "Everything in this room has changed and I don't recognize it anymore."

C. "My hands and feet are much smaller than they used to be." Rationale: The client who experiences depersonalization might feel that parts of her body belong to someone else or are different in some way. Depersonalization is experienced as a loss of personal identity. Feeling that the client's environment has changed in some way is an example of derealization, rather than depersonalization.

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? A. "You need to tell the voices to leave you alone." B. "You need to understand that there are no voices." C. "What are the voices telling you to do?" D. "Why do you think you are hearing the voices?"

C. "What are the voices telling you to do?" Rationale: This statement recognizes the risk involved with a command hallucination and asks the client directly about the hallucination. This is a therapeutic approach to communicating with a client who is experiencing a hallucination.

A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make? A. "You should be aware that excessive sleeping is an early sign of relapse." B. "Relapse is an indication that you are not taking your medications properly." C. "You should keep your provider's and therapist's number with you." D. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."

C. "You should keep your provider's and therapist's number with you."

A nurse is caring for a client who has schizophrenia who consistently does the opposite of what the nurse asks of him. The nurse recognizes this as which of the following alterations in behavior? A. Automatic obedience B. Waxy flexibility C. Active Negativism D. Impaired impulse control

C. Active Negativism

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.) A. Delusions B. Hallucinations C. Anhedonia D. Poor judgment E. Blunt affect

C. Anhedonia E. Blunt affect

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take? A. Act to the client as if the hallucination is real. B. Instruct the client to argue with the voices that are a part of the hallucination. C. Ask the client direct questions about the hallucination. D. Tell the client that the hallucination is not a part of reality.

C. Ask the client direct questions about the hallucination.

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? A. Rotate staff assignments for this client. B. Use touch to calm the client during periods of anxiety. C. Check the client's mouth after the client takes medication. D. Assign an assistive personnel to feed the client at mealtimes.

C. Check the client's mouth after the client takes medication.

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address? A. Visual hallucination B. Gustatory hallucination C. Command hallucination D. Tactile hallucination

C. Command Hallucination

The nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication?

Contractions of the jaw

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? A. "This medication will help prevent seizures." B. "This medication will be administered by intramuscular injection every 2 weeks." C. "I should expect to develop ringing in my ears while taking this medication." D. "I will rise slowly from a lying position to prevent fainting while taking this medication."

D. "I will rise slowly from a lying position to prevent fainting while taking this medication."

A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention? A. "It sounds frightening to feel like both God and the devil at the same time." B. "I don't understand. Can you tell me what that means?" C. "Are you saying that you are both good and bad?" D. "There is no gate for me to open.

D. "There is no gate for me to open." Rationale: This reply can be viewed as argumentative by the client and is non-therapeutic for communicating with a client who is experiencing a delusion.

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching? A. "You will need to consume a low-salt diet while on this medication." B. "You will need your blood levels drawn weekly during the first month." C. "You will need to take this medication on an empty stomach." D. "You will need to stop this medication if you experience diarrhea.

D. "You will need to stop this medication if you experience diarrhea." Rationale: Diarrhea can lead to dehydration and potentially elevated lithium levels and toxicity. Diarrhea, vomiting, and lethargy can also indicate lithium toxicity. The nurse should inform the client to stop taking the medication if the any indications of lithium toxicity occur.

A nurse is planning to administer haloperidol to a client who has acute psychosis. The nurse should monitor the client for which of the following findings as an adverse effect of the medication? A. Excess salivation B. Increased agitation C. Diarrhea D. Dystonia

D. Dystonia Rationale: The nurse should monitor the client for dystonia after administering Haloperidol. Dystonia is a repetitive muscular contraction that may cause twisting of the body.

A nurse is reviewing the medication administration record of a client who has schizophrenia. The nurse should plan to initiate the abnormal involuntary movement scale to monitor for adverse effects of which of the following medications?

Haloperidol

A nurse is reviewing the medical record of a client who has schizophrenia and is receiving olanzapine. Which of the following findings should the nurse identify as an adverse effect of olanzapine?

Weight gain of 3 lb in 2 weeks.

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates concrete thinking? A. "I am aware that each problem has only one solution." B. "I am a prophet of the most high king." C. "The voices tell me that I must avoid large crowds." D. "I know that you and the other nurses are trying to poison me."

A. "I am aware that each problem has only one solution."

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. A client who has a WBC of 2,900 cells/mm3 B. A client who has a hematocrit of 55% C. A client who has a serum potassium of 3.3 mEq/L D. A client who has a BUN of 22 mg/dL

A. A client who has a WBC of 2,900 cells/mm3

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. A private room in a quiet location on the unit B. A semi-private room with a roommate who has a similar diagnosis C. A private room close to the nursing station D. A seclusion room until the client's activity level becomes more subdued.

A. A private room in a quiet location on the unit Rationale: A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.

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? A. Affective flattening B. Bizarre behavior C. Illogicality D. Somatic delusions

A. Affective flattening

A nurse is caring for a client who has schizophrenia. The client states that he hears voices telling him to "do bad things". The nurse correctly identifies this finding as which of the following? A. Command hallucination B. Gustatory hallucination C. Cognitive distortion D. Somatic delusion

A. Command hallucination

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? A. Dysrhythmias B. Cataracts C. Pancreatitis D. Bleeding

A. Dysrhythmias

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may increase lithium toxicity? A. Experiencing diarrhea B. Exercising moderately C. Increasing sodium intake D. Drinking green tea

A. Experiencing diarrhea Rationale: Lithium is used to treat the manic stage of bipolar disorder. Toxicity occurs when the level of lithium in the blood becomes too high. A low sodium level, or factors which result in a low sodium level, (such as dehydration, diarrhea, sweating, excess exercise in hot weather, diuretic use, a low sodium diet) increases the lithium level because the kidney processes sodium and lithium in the same way. If sodium levels fall, the body conserves lithium, causing lithium levels to rise.

A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high level official to visit me!" The nurse responds, "I understand, but it is time for group therapy and we expect everyone to attend. Let's walk over together." For which of the following reasons is the nurse's response considered therapeutic? A. It clearly articulates what is expected of the client. B. It demonstrates empathy towards the client. C. It sets limits on the client's manipulative behavior. D. It uses reflection when talking with the client.

A. It clearly articulates what is expected of the client.

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.) A. Muscle spasms of the neck B. Fidgeting behavior C. Blurred vision D. Tremors of the hands E. Sexual dysfunction

A. Muscle spasms of the neck B. Fidgeting behavior D. Tremors of the hands

A nurse is assessing a client who has schizophrenia and is taking aripiprazole. The nurse should notify the provider of which of the following findings? A. Muscle stiffness B. Insomnia C. Constipation D. Weight gain of 5 lb in 1 month

A. Muscle stiffness Rationale: Muscle rigidity is a manifestation of neuroleptic malignant syndrome, which is a potentially serious adverse effect of aripiprazole, and should be reported to the provider immediately. Insomnia, constipation and weight gain are all expected adverse effects of airpiprazole.

A nurse is caring for a client who has a serum lithium of 2.0 mEq/L. Which of the following is the priority action for the nurse to take? A. Notify the primary provider the result indicates toxicity. B. Continue to monitor this expected maintenance level. C. Request the provider increase the client's medication dose. D. Check the client for manifestations of hypernatremia.

A. Notify the primary provider the result indicates toxicity. Rationale: The therapeutic reference range for lithium is 0.8-1.4 mEq/L. The nurse should recognize the client could require hospitalization and report the finding to the provider. The nurse should check the client for findings associated with advanced to severe lithium toxicity like vision changes, neurological impairment, and hypotension.

A community mental health nurse is assessing a client who has schizophrenia. Which of the following findings indicates the client might be relapsing? A. The client reports difficulties with sleeping and concentrating. B. The client states he has started smoking again. C. The client is wearing mismatched clothing. D. The client reports feelings of anger toward her provider.

A. The client reports difficulties with sleeping and concentrating.

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? A. The client runs 4 miles outdoors every afternoon. B. The client drinks 2 liters of liquids daily. C. The client eats 2 to 3 gm of sodium-containing foods daily. D. The client eats foods high in tyramine.

A. The client runs 4 miles outdoors every afternoon. Rationale: Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and sodium that have been lost through profuse sweating. This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics.

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take? A. Withhold the medication. B. Prepare to administer propranolol. C. Administer the next dose as prescribed. D. Plan to administer levothyroxine.

A. Withhold the medication. Rationale: The nurse should withhold the medication, because the client is displaying manifestations of toxicity, which includes ataxia, confusion, large output of dilute urine, blurred vision, clonic movements, seizures, stupor, severe hypotension, and coma. Pulmonary complications may lead to death.

A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following client statements indicates an understanding of the teaching? A. "This medication will help me stop smoking." B. "I may have a dry mouth while taking this medication." C. "I should expect flu-like symptoms while taking this medication." D. "This medication may cause me to urinate frequently.

B. "I may have a dry mouth while taking this medication." Rationale: Chlorpromazine causes anticholinergic effects, such as dry mouth and constipation.

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? A. "You are mistaken. Nobody is lying about you or trying to poison you." B. "You seem to be having very frightening thoughts." C. "Why do you think you are being lied about and poisoned?" D. "Who is lying about you and trying to poison you?"

B. "You seem to be having very frightening thoughts."

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? A. Prepare for gastric lavage due to an extremely elevated lithium level. B. Administer the morning dose of lithium. C. Check the client's medication record to assess whether the client has been refusing her lithium. D. Hold the medication and assess for early manifestations of toxicity

B. Administer the morning dose of lithium. Rationale: The nurse should administer the lithium dose since a lithium level of 1.0 mEq/L is within the expected initial therapeutic range of 0.8 to 1.3 mEq/L. At a therapeutic level the client might demonstrate adverse effects of lithium, such as a fine hand tremor, thirst, and mild nausea, and the nurse should note if any of these manifestations are present. The nurse should continue to monitor for adverse effects and signs of toxicity, which usually occur at levels of 1.5 mEq/L or higher.

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yester noon the sun moon went over the rover to see the lawnmower." Which of the following manifestations is the client exhibiting? A. Delusional disorder B. Associative looseness C. Hallucination D. Anhedonia

B. Associative looseness

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? A. Fluvastatin B. Carbamazepine C. Lorazepam D. Propranolol

B. Carbamazepine Rationale: Carbamazepine, an antiseizure medication and a mood stabilizer, is prescribed to treat and prevent mania in clients who have bipolar disorder.

A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions? A. Persecution B. Control C. Erotomanic D. Somatic

B. Control

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? A. Flight of ideas B. Grandiosity C. Reality testing D. Derealization

B. Grandiosity

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care? A. Provide a stimulating environment. B. Have consistent unit routines. C. Discourage daytime napping. D. Schedule daily seclusion times.

B. Have consistent unit routines. Rationale: The nurse should implement consistent routines to provide the client with a sense of security. Clients who are experiencing mania might require seclusion. However, this technique should only be implemented when specifically warranted by the client's behavior.

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? A. Place the client in seclusion if visual hallucinations are present. B. Limit the number of questions asked during assessments C. Use frequent touch to provide client support. D. Directly tell the client that delusions are not real.

B. Limit the number of questions asked during assessments

A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 103.4F, BP of 150/110 mm Hg and muscle rigidity. Which of the following complications should the nurse suspect? A. Agranulocytosis B. Neuroleptic malignant syndrome C. Akathisia D. Tardive dyskinesia

B. Neuroleptic malignant syndrome

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring? A. Tardive dyskinesia B. Neuroleptic malignant syndrome C. Acute dystonia D. Pseudoparkinsonism

B. Neuroleptic malignant syndrome Rationale: The client's findings indicate possible neuroleptic malignant syndrome which is a potentially life-threatening adverse effect of antipsychotic medications. The nurse should promptly recognize and report findings of neuroleptic malignant syndrome since prompt treatment is necessary.

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? A. A blood lithium level of 1.8 mEq/L is not within the maintenance treatment level. B. The lithium level is at the toxic level. C. The lithium level is below the therapeutic treatment level. D. The lithium level is within the therapeutic level for initial treatment.

B. The lithium level is at the toxic level. Rationale: A blood lithium level greater than 1.5 mEq/L indicates toxicity. The nurse should monitor the client for GI manifestations, coarse hand tremor, confusion, drowsiness, and should withhold the lithium and notify the provider. A therapeutic initial blood level of lithium is 0.8 to 1.4 mEq/L. Blood levels for lithium maintenance should be between 0.4 and 1.3 mEq/L.

A nurse is assessing a client who has schizophrenia. Which of the following behaviors should the nurse anticipate? A. Periods of elation with unusual talkativeness B. Preoccupied with folding clothes C. Invents words that have no meaning D. Recurrent thoughts of past trauma

C. Invents words that have no meaning

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? A. Thyroid function tests should be performed every 6 months. B. A pretreatment electroencephalogram (EEG) will be done. C. Liver function tests must be monitored. D. High serum sodium levels can cause toxic levels of valproate.

C. Liver function tests must be monitored. Rationale: Pancreatitis, hepatic dysfunction, and thrombocytopenia are serious adverse effects occasionally associated with valproate. Liver function tests should be monitored periodically to check for hepatic failure

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? A. Echolalia B. Clang association C. Neologism D. Word salad

C. Neologism

A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take? A. Turn on a dance video so the client can burn off excess energy. B. Offer the client a low-calorie snack in return for stopping the behavior. C. Take the client outside and sit with her in the garden area. D. Observe the client closely for the development of aggressive behavior.

C. Take the client outside and sit with her in the garden area. Rationale: It is appropriate to remove the client from the stimulating environment and to use instruction, rather than bargaining, to decrease the activity level. Additionally, the nurse's presence provides security and support to the client.

A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention? A. Recommend a game of table tennis with another client. B. Suggest the client exercise on a stationary bike. C. Take the client outside for a walk. D. Praise the client's efforts to engage in social interaction

C. Take the client outside for a walk. Rationale: Clients who are experiencing mania are at risk for physical exhaustion; therefore, the nurse should redirect the client to a different activity that will decrease stimulation and slow the client's physical activity expenditure.

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania? A. The client's spouse reports that client has recently gained weight. B. The client is dressed in all black. C. The client responds to questions with disorganized speech. D. The client reports that voices are telling him to write a novel.

C. The client responds to questions with disorganized speech. Rationale: Clients who are experiencing acute mania exhibit disorganized speech such as a flight of ideas.

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? A. The client has begun playing basketball with several other clients during the past month. B. The client identifies with problems expressed by other clients. C. The client's behavior has become impulsive in the past few weeks. D. The client states she wants to go home to be with her children and partner.

C. The client's behavior has become impulsive in the past few weeks. Rationale: The presence of impulsive behavior is a primary risk factor for suicide and clients who have mania can act in a manner which is hostile, aggressive, and impulsive.

nurse is reviewing the medical record of a client who has a prescription for clozapine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to clozapine? A. Asthma B. Fasting blood glucose 120mg/dL C. WBC count 3,300/mm3 D. Hypertension

C. WBC count of 3,300/mm3

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? A. Identifying support systems. B. Assisting the client in identifying coping behaviors. C. Encouraging self-care D. Preventing self-directed violence.

D. Preventing self-directed violence. Rationale: Identifying support systems, identifying coping behaviors and encouraging self-care are all appropriate actions. However, they do not address the greatest safety risk to the client and is therefore not the priority.

A nurse in a mental health facility is preparing to interview a client who has schizophrenia. Which of the following actions should the nurse take? A. Sit on the other side of a table from the client. B. Place the client in a chair higher than the nurse. C. Start the interview with a question the client can answer with a "yes" or "no." D. Sit beside the client rather than facing him.

D. Sit beside the client rather than facing him. Rationale: The nurse should sit beside the client or at a 90 angle from him so that direct eye contact is unnecessary. Sitting facing the client directly can cause him to feel uncomfortable and can make the interview more intense.

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)? A. Shuffling gait B. Constant tapping of feet when sitting C. Sudden onset of high fever D. Twisting tongue movements

D. Twisting tongue movements Rationale: Twisting tongue movement, tics, sudden involuntary jerking movements of the extremities, and other findings occur in TD. The nurse should notify the provider of these findings since treatment includes reducing dosage of antipsychotic medications or perhaps changing to a second-general antipsychotic medication.

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? A. Expect to have your blood checked weekly for serum electrolyte imbalances B. Have your blood pressure checked frequently for hypertension. C. Increase caloric intake to prevent weight loss. D. Increase your fluid and fiber intake to prevent constipation

Increase caloric intake to prevent weight loss

A nurse is developing a care plan for a client who has schizophrenia and is taking chloropromazine. Which of the following actions should the nurse include in the plan?

Monitor the client's respirations every 4 hours.(Chlorpromazine can cause resp. depression, dyspnea, and laryngospasm.)

A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should consult with which of the following members of the interdisciplinary team to assist the client? A. OT B. ST C. CNA D. PT

Occupational Therapist

A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should be nurse include in the teaching?

You should discontinue this medication if you develop muscle rigidity

pt has new script for iloperidone.what does pt state that indicates an understanding of the teaching

i will be careful not to gain too much weight while on this med