NUR 205 Saunders Mental Health

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement?

"Are you fearful and think that others may want to hurt you?"

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use and what effect does it have on you?"

A psychiatric client diagnosed with schizophrenia approaches the nurses' station and shouts, "Shut up. I told you to be quiet." Looking at the nurse, the client says, "Can't you hear them shouting at me?" Which would be the nurse's best response?

"I don't hear the voices, but I can see how upsetting it must be for you."

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

1. "I notice you are wearing a blue shirt." 2. "Do you have any plans of harming yourself?" 4. "I will sit here with you even if you choose not to talk with me."

A client is admitted to the mental health unit with a diagnosis of possible somatic symptom disorder. Besides anxiety, the nursing assessment is especially important in identifying which client signs/symptoms are contributing to the somatic symptom disorder? Select all that apply.

1. Depression 2. Substance abuse 4. Adverse childhood events 5. Posttraumatic stress disorder (PTSD)

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. Which best intervention should the nurse include when formulating a plan of care?

Avoid using a whisper voice in front of the client.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

The nurse reviews the activity schedule for the day and determines that which supervised activity is the best option for the manic client?

Ping-pong

The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations?

Discuss common fears and questions expressed by other clients with the same diagnosis.

In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best?

Encourage the client to participate in a structured daily program of activities.

A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first?

Examine the neck area and assess the airway.

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least likely to be helpful to this client at this time?

Initiate confinement measures

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client and offer to take her for a walk.

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?

Looking for organic causes of the paralysis.

A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room and talk about his feelings.

The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs/symptoms of anxiety and attempts to assist the client back to the client's hospital room. Which is the next appropriate nursing action at this time?

Notify the registered nurse (RN).

A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which to assist the client in meeting nutritional needs?

Provide small, frequent meals.

A client is admitted to the psychiatric unit following a serious suicide attempt by a drug overdose. Which action should the nurse implement?

Remain with the clients at all times.

The nurse is assisting in preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to care for the client to improve communication. Which action would be appropriate for the nurse to suggest including in the plan of care?

Reward the client when a desired behavior is performed.

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need?

Safety and security

The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial?

Share the observation with the client and help the client recognize his or her feelings.

The nurse is caring for a client diagnosed with somatic symptom disorder who continuously complains of a severe headache. Which interventions are most appropriate when planning care for this client?

Shift the focus from the client's somatic concerns to feelings and coping skills.

The nurse is assisting in conducting a group therapy session. During the session a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate nursing action?

Tell the client that he may talk about his anger but cannot act on it during the group session.

The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action?

Telling a friend that this employee hates her.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note?

The client will participate in the treatment plan.

The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?

The client will resolve feelings of fear and anxiety related to the rape trauma.

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?

The false belief that one is being singled out for harm by others.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action?

Use a night light and turn off the television.

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which?

"Our relationship is a therapeutic and a helping one."

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client?

"Tell me about your difficulty sleeping."

While the nurse is providing care, a client angrily reports to the nurse that the primary health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which nursing response would likely be a barrier to further communication with the client?

"The primary health care provider would never lie to you."

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

Use an indirect light source and turn off the television.

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crises for another person.

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?

"Tell me more about what causes you to feel like the rape just occurred."

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply.

1. Monitor vital signs. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 6. Provide reality orientation as appropriate.

Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply.

1. Poor limit setting 2. Staff inexperience 3. Provocative or controlling staff 4. Arbitrary revocation of privileges.

The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply.

1. Promoting self-care and independence. 4. Facilitating communication of distressing thoughts and feelings. 5. Helping clients examine self-defeating behaviors and test alternatives. 6. Assisting clients with problem solving to help facilitate activities of daily living.

The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply.

1. Respond to stimuli 2. Conduct electrical impulses. 5. Release chemicals called neurotransmitters.

The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.

3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations.

The nurse assists in making a plan of care for a client and is developing goals that will help the client achieve an optimal level of functioning and use resources. When the nurse enters the client's room, the client says to the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which nursing response is appropriate to assist the client in achieving the goal that has been set for this client?

"When the psychiatrist arrives on the unit, I will let her know that you have a question."

The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply.

1. Refer to hallucinations as if they are real. 2. Ask the client directly about hallucinations. 5. Watch the client for cues that he or she is hallucinating, such as eyes tracking an unheard speaker, muttering, or talking to self. 6. Address any underlying emotion, need, or theme that seems to be indicated by the hallucinations, such as fear with menacing voices or guilt with accusing voices.

A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply.

1. Sit by the client's bed holding his or her hand. 2. Reminisce with the client and share a humorous story that the clients enjoys. 3. The nurse asks: "What can I do, that make you feel more comfortable today?" 5. The nurse asks: "I noticed you grimacing earlier when I walked in your room. Are you in pain?" 6. The nurse states: "It must be very frustrating to be in pain and not be able to get complete relief from your pain."

An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, which is the priority nursing action?

Notify the social worker to investigate the situation.

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand and obtain release from the hospital.

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment should include which intervention?

The client shampoos and dries the hair, freeing it all of hair spray and creams.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?

The client is at increased risk for suicide.

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?

Tell the client that the primary health care provider will be contacted regarding discharge.

The nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's blood pressure is elevated at 160/100 mm Hg. Based on this finding, which nursing action would be appropriate?

Notify the registered nurse.