NURS 165 Final

A nurse is providing teaching about physical and psychosocial effects of stress to school-aged children. What level of prevention does this demonstrate? Primary prevention Secondary prevention Tertiary prevention Quaternary prevention

Primary prevention

A nurse is teaching a client who was diagnosed with prolonged grief disorder due to the loss of a significant other, about the importance of CBT. What is the goal of CBT for this client?

"Cognitive behavioral therapy will help me figure out how to live with the loss of my partner"

A charge nurse is meeting with a newly licensed nurse who states they have been experiencing moral conflicts when providing care for some clients. The charge nurse should recognize that the nurse's feelings place them at risk for which of the following actions? Using nonverbal cues when caring for clients Initiating inclusion when planning care for clients Becoming too involved with the clients Providing a lower quality of care to the clients

Providing a lower quality of care to the clients A nurse who commonly experiences moral conflicts is more prone to provide lower quality of care to clients and is at risk of experiencing burnout.

A nurse is discussing the plan of care with the guardian of a child recently diagnosed with a neurodevelopmental disorder. The guardians tell the nurse that they are opposed to any medication intervention. Which actions should the nurse take>?

Recommend the use on nonpharm interventions to the child's provider, educate the guardians on importance of routines and therapy.

A nurse is caring for an adolescent who had an ACE and was admitted to the unit with behavioral problems. The nurse should anticipate the pricder prescribing what type of treatment?

CBT

A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing depression with __________ features and is having persecutory _________

Psychotic and delusions

Inpatient MH clients must do what before taking antipsychotic medications?

Sign medication consent form

True or false: client with bulimia nervosa is preoccupied with their body shape

true

A nurse has described the behavioral health unit being based on milieu therapy to a client. The client asks, "How is a unit which has milieu therapy different from other hospital units?" Which of the following responses should the nurse make? "A mental health unit, which includes milieu therapy, is focused on stabilizing clients who are in an acute phase of mental illness." "A mental health unit, which includes milieu therapy, is less intensive, focusing only on one psychiatric illness or substance abuse disorder." "A mental health unit, which includes milieu therapy, is focused on long-term care of clients who have specific mental health disorders." "A mental health unit, which includes milieu therapy, ensures every aspect of care is intentionally focused on creating a safe and therapeutic environment."

"A mental health unit, which includes milieu therapy, ensures every aspect of care is intentionally focused on creating a safe and therapeutic environment." This response describes what the purpose of milieu therapy would bring to a behavioral health unit. Milieu therapy can be used in any mental health setting and the focus is on creating and maintaining a safe therapeutic environment, rather than on the clients' type of mental health disorder or client conditions.

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkept and unbathed. How do you get them to shower?

"It is time for you to bathe now. Do you want to wear the green or the red shirt?

A nurse in an outpatient behavioral facility is caring for a client who has substance use disorder and a history of violence. What should the nurse identify as being consistent with ACEs?

"My parent went to prison when I was 12." "My parents divorced when I was 13."

A nurse is caring for a client who asks the nurse, "May I please have your home address so that I can send you a note after I get home?" Which of the following responses should the nurse give? "Sure, I will write it down for you." "I know you are looking forward to being at home again and having a normal routine." "Thank you for your kind words. Unfortunately, I am not allowed to share my home address by policy of the hospital." "Absolutely not! We are not allowed to give out our personal information!"

"Thank you for your kind words. Unfortunately, I am not allowed to share my home address by policy of the hospital." The nurse should thank the client and explain why they are not allowed to share their personal information.

5 year history of schizo. Multiple hospitalizations for psychosis and depression. Has had ECT in the past, drinks 4-5 ETOH drinks per day. smokes one pack per day. reports no drug use, no surgeries, HTN, HLD, and cirrhosis. which meds are anticipated and which are contraindicated?

Risperdone and zipradone indicated quetiapine and haloperidol contraindicated

A nurse is providing care to a client who is aggressive and demonstrating self-injurious behaviors. Which of the following disorders does the nurse ID as being consistent with this behavior?

ASD

To ensure a psychologically safe milieu how should a MH nurse manage a bipolar client who is. making sexually inappropriate comments during a group therapy session?

Address the behavior immediately Clearly define expectations and boundaries. Enforce boundaries Have client sign behavioral contract if necessary

A nurse is caring for a client who was removed from their family home as a child due to neglect. Which of the following terms is used to signify this occurence?

Adverse Childhood Experience (ACE)

A charge nurse on a mental health unit is describing assessments for suicide risks to a group of newly licensed nurses. Which of the following tests should the nurse include?

SAFE-T, SAD PERSONS, Columbia-Suicide Severity Rating Scale (C-SSRS)

A nurse is discussing a trauma-informed approach to care with a peer. The following statement is an example of. "To keep clients safe and promote healing, it is important to intentionally consider my words and actions."

Self-reflection

A staff nurse completes orientation to a psychiatric unit. This nurse may expect an advanced practice nurse to perform which additional intervention? a. Conduct mental health assessments. b. Prescribe psychotropic medication. c. Establish therapeutic relationships. d. Individualize nursing care plans. e. establish the client's goals.

ANS: B In most states, prescriptive privileges are granted to master's-prepared nurse practitioners and clinical nurse specialists who have taken special courses on prescribing medication. The nurse prepared at the basic level is permitted to perform mental health assessments, establish relationships, and provide individualized care planning.

A nurse is caring for a client who was hospitalized with a high blood ETOH level. THe provider fears the client may go into w/d and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100, and tachypnea, one hour ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol w/d?

Stage 3 (severe), DTs

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting warning signs of suicide?

A client who is giving away their possessions

What is the difference between a suicide attempt and self-harm?

A suicide attempt is when a person harms themself with the intent to die but does not. Self-harm is when a client intentionally inflicts harm on themselves but does not have intention to kill themselves

A nurse is caring for an adolescent client whose close friend recently died by suicide. The client tells the nurse, "I should have called back when they texted me. If I had been there, my friend would still be alive." What should the nurse understand from this statement? A. This is an expression of emotional pain, and the client needs to be closely monitored B. This is an expression of normal grief, and the client will respond well if they can just express their feelings C. This is an expression of delayed grief response, and the client is expressing their thoughts and feelings D. This is an expression of a lack of self-compassion, and the client needs to focus on being kind to themselves

A this is emotional pain and feelings of guilt from a traumatic loss. It is important for this client to be closely monitored for safety

A nurse is discussing therapeutic milieu with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates and understanding of therapeutic milieu? A. "The milieu consists of the physical and psychosocial environmental factors." B. "A therapeutic milieu requires unstructured programming, allowing clients to focus on their interests." C. "The gathering spaces should have the chairs positioned around the perimeter of the day room." D. "The clients can keep any personal items they would like in their rooms."

A. "The milieu consists of the physical and psychosocial environmental factors."

A nurse is caring for a client who is experiencing manifestations of opiate w/d. When assessing the client, which of the following purposes describes the function of the Clinical Opiate Withdrawal Scale (COWS)?

Assess severity of symptoms from w/d and treat accordingly

A nurse is caring for a client and notes that the client appears disheveled, frightened, and seems to be talking to someone who is not there. The nurse should identify that this is an example of which of the following steps of the nursing process?

Assessment

A nurse manager and a newly licensed nurse are engaged in an interview with a client. The newly licensed nurse tells the client, "You look like my sister. I love my sister and would do anything for her." Which of the following actions should the nurse manager take? Record that the newly licensed nurse is able to maintain professional nurse-client boundaries. Assign the newly licensed nurse to a different client. Ask the newly licensed nurse if they are comfortable providing care to the client. Inform the newly licensed nurse that they are successfully building trust and rapport.

Assign the newly licensed nurse to a different client. If the nurse manager determines that the newly licensed nurse might have emotions or feelings towards the client that could compromise a professional relationship, they should assign this client to a different nurse.

SMI has periods of relapse and remission. What is a s/s you expect in a patient who is experiencing a relapse of schizophrenia?

Auditory and visual hallucination. "I do not understand why the hallucinations have come back"

A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. What education about this medication should the nurse provide?

Avoid driving or operating heavy machinery until you know how alprazolam affects you.

A nurse is caring for a client who is experiencing manifestations of ETOH w/d. Which of the following medications should the nurse anticipate the provider prescribe and why?

Benzodiazapines - prevent seizures, hallucinations, agitation

A client with a leg fracture shares personal feelings about the accident with a nurse and says, "I feel guilty because the accident was my fault. I will be unable to support my family." What is the most therapeutic action by the nurse? Console the client. Describe a similar incident. Give a sedative to relax the client. Sit beside the client and listen attentively, and summarize the client's comments.

Sit beside the client and listen attentively, and summarize the client's comments. Attending to a client and listening to him or her carefully is a good therapeutic action. It is a way for the client to share his or her feelings. Consoling the client is a sympathetic response though not the most therapeutic. By describing a similar incident, the nurse is taking the focus off the client. Giving a sedative is not necessary in this situation.

Why is therapeutic communication important in MH nursing? A. "Therapeutic communication is only necessary for severe mental health issues." B. "Therapeutic communication is mainly focused on entertaining the client rather than addressing their mental health concerns." C. Key component of mental health nursing and the therapeutic nurse-client relationship that improves the emotional wellbeing of the client. D. "Establishing a nurse-client relationship is a time-consuming process with minimal impact on client wellbeing."

C. Key component of mental health nursing and the therapeutic nurse-client relationship that improves the emotional wellbeing of the client.

A nurse is caring for a 9-year-old child who is shy and fearful. The nurse asks the child a question, but the child does not answer immediately. What is the best approach by the nurse to develop a therapeutic relationship with the child? a. explain the questions with medical words b. Use common cliche's when asking questions c. remain silent after asking a question to allow the client a chance to respond d. tell the child the consequences of not answering

C. Remain silent after asking a question to allow the child a chance to respond. Silence offers an opportunity for the child to answer spontaneously and cautiously. More information is usually forthcoming if the nurse gives the child the opportunity to respond. All other choices are could potentially interfere with communication in the pediatric population.

A nurse is preparing an inservice about behavioral disorders. Which of the following factors should the nurse suggest using when distinguishing between the behavior of a child who has Oppositional defiant disorder versus conduct disorder.

Clients who have ODD test limits and disobey authority figures Clients who have CD often violatre the rights of others Clients who have CD do not always follow societal norms

A nurse is caring for a client who has schizophrenia and has been taking a first generation medication for several years. The client is exhibiting jerking movements and twitching of the face and tongue. What is the patient experiencing?

Tardive dyskinesia

A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as a comorbidity to this condition and why? Alzheimer's OA DM Cancer

DM, adverse effect of second generation antipsychotics

What are the three criteria for a 5150 hold?

DTS, DTO, GD

A nurse is caring for a client who is experiening manifestations of opiate withdrawal. What medication should the nurse anticipate the provider to prescribe?

methadone, suboxone, subutex

A group of nurses is discussing the purpose of mental health documentation. Which of the following descriptions of nursing documentation for a mental health client is accurate?

Documentation for mental health clients provides a record of the nurse's awareness of client behaviors, mental status, interventions, and client response.

A nurse is caring for a client who is experiencing delusions, hallucinations, and alterations in speech. Which class of medications should the nurse anticipate the provider to prescribe?

Dopamine antagonist/antipsychotics

A nurse is teaching a parent about communicating with their teenage child who has anorexia nervosa. This is an example of which of the following types of therapy?

Family based therapy

A nurse is providing d/c teaching to a client who has BPD. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

offer the client information about a support group for the parent

A nurse is working to build rapport and trust with new clients. Which of the following actions should the nurse take? Explain the importance of treatment to a client who speaks a language different from the nurse. Use clinical terminology to help a client better understand their diagnosis. Fulfill a promise by allowing a client to visit with family members. Minimize contact with a client who is angry.

Fulfilling a promise by allowing a client to visit with family members is an example of how to build RAPPORT and trust with new clients. This action by the nurse demonstrates fidelity, which in turn builds rapport.

A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should ID that these manifestations indicate which disorder?

GAD

Examples of a grandiose delusion and a persecutory delusion

Grandiose: I am a famous person or celebrity Persecutory: there are a gang of thugs out to get me, they want to beat me up.

______ are and indication of severe alcohol w/d also known as ________

Hallucinations, Delirium Tremens

A 38-year-old client who has schizophrenia is admitted. Diagnosed 15 years ago. BP 156/92. Client reports, "I have been hearing voices again telling me to hurt myself. I hear the voices at night time so I am not sleeping well." Later the client is standing on his bed and states, "Do you see that man? He is telling me he is going to hurt me." Client is point to corner of room, talking to themselves and states, " I don't want to hurt myself. Tell the voices to go away!' The nurse asks the client who they are talking to and states,. "Tell me more avout who is trying to hurt you." What needs to be addressed ASAP?

Hallucinations, delusions, and BP

The client's family states that the client "took some kind of drugs". The client is dizzy, just vomited, and is experiencing paranoia, yelling "Stay away from me! You are going to kill me!" The client alternates yelling with mumbling and gesturing. Their eyes are darting back and forth as they are talking to the wall. The ED nurse should suspect the client has used which of the following substances?

Hallucinogens

A MH nurse is utilizing milieu therapy to provide a therapeutic environment for their clients. Which of the following steps of the nursing process is the nurse demonstrating?

Implementation

A nurse is reviewing ethical principles with a newly licensed nurse. The nurse should include which of the following as an ethical principle. Justice HIPPA Bias "Duty to Warn"

Justice - In mental health there are ethical principles that guide how nurses should act regarding ethical issues. Ethical principles can include beneficence, autonomy, and justice. The American Nurses Association has a code of ethics that assists in guiding nurse in how to make ethical decisions in health care.

What are some negative symptoms of schizophrenia?

LACK OF EMOTION, flat affect, social withdrawal, lack of volition

A nurse is discussing torts with a newly licensed nurse. Which of the following information should the nurse include? False imprisonment does not apply to use of chemical restraints. Battery occurs when a person verbally threatens to harm another person. Negligence is the most common unintentional tort. Assault is a tort that only occurs if a client is physically harmed.

Negligence is the most common unintentional tort. Negligence is the most common unintentional tort and can be committed by anyone. For example, negligence can occur when a guardian does not provide adequate nutrition for their minor child.

When should a nurse discuss the restraint and seclusion policy with a client? After administering antipsychotics On admission At time of discharge While restraining the patient

On admission

A client is prescribed alprazolam. Which action must the nurse include in the client assessment during the initiation of therapy? Measure the client's urine output. Examine the client's pupils daily. Check the client's blood pressure. Assess the abdomen for distention.

Orthostatic hypotension is a common side effect of alprazolam that occurs early in therapy, so checking the client's blood pressure is the appropriate action. An alteration in urine output is not a common side effect, but it may occur after prolonged use. Central nervous system depression is not an early side effect, but it may occur after prolonged use; examining the client's pupils daily is not appropriate at this time. Distention is not a common side effect, but distention from constipation may occur after prolonged use.

A nurse is caring for a client who has a prescription for a bone densiometry test. The nurse should ID that this test is used to assess for which of the following conditions?

Osteopenia

A nurse is educating a client about automatic refills of prescribed medications. This nursing intervention is an example of what level of prevention? Primary Prevention Secondary Prevention Tertiary Prevention Quaternary Prevention

Tertiary prevention - management of chronic diseases, and rehabilitation support services to slow down the progression of diseases Secondary Prevention: health assessment and screening to facilitate early ID of chronic diseases Primary Prevention: Health promotion, advisory and counseling services and educational programs to drive lifestyle changes for the prevention of chronic diseases Quaternary: I dont event know what this is. just another multiple choice answer

Why do some people who take medication experience resolution of clinical manifestations of their mental illness while other people experience relapses or worsening clinical manifestations?

The brains ability to adapt is very individual and plays a role in symptom severity

The community health nurse is visiting a client with a history of alcohol abuse and attempted suicide. Which action by the client alerts the nurse to engage against suicidal​ ideation? A.The client gives the nurse a special personal possession. B.The client has discarded all old unused medication. C.The client attends Alcoholics Anonymous meetings. D.The client has started a new romantic relationship.

The client gives the nurse a special personal possession.Rationale: Giving away a personal possession is a sign that the client may be preparing to end his​ life, so the nurse would take immediate action to diminish suicidal ideation. Withdrawing from relationships would be a warning sign. Looking for pills or another​ tool, like a​ gun, would be an alert for suicide. Lapsing back into alcohol or substance abuse would increase the risk of suicide.

A nurse has been confronted about stealing and taking drugs from the narcotics cart in the med room. The nurse has been reported to the board of nursing in their state. What is likely the initial outcome

The nurse will be assisted into drug treatment

What criteria must be met before the nurse can remove the restraints from an aggressive patient?

The patient must be calm and cooperative - not a danger to themself or others

A nurse is caring for a client who was recently re-admitted for relapse of psychosis symptoms due to not taking their medications, or a patient with SUD who began who began drinking again, or a patient with bulimia that began binding/purging. Which of the following should be a long-term goal for this client?

To develop and acknowledge understanding of relapse plan prior to d/c

A nurse is providing care for a client who has recently returned from active combat and experienced the loss of a close friend during combat. If they make the following statement, what kind of grief are they experiencing? "I should have been the one who was killed instead of my friend."

Traumatic grief/complicated grief/survivor's guilt

What is the goal of ECT and what does the client experience during the procedure?

Treatment of severe treatment resistant depression - patient experiences seizure like activity within the brain

True or False: tachycardia and vomiting are symptoms of ETOH w/d

True

True or false: the younger you start using a substance the more likely you are to develop SUD

True: exposing the brain to substances at an. early age is a risk factor for developing SUD

A nurse is interviewing a client who states, "I am at a total loss and don't know what to do anymore. I feel hopeless." Which of the following responses should the nurse make?

You feel like you have no remaining options and are struggling to find a solution

A nurse is assessing a 12-year-old child who recently shot a dog with a pellet gun and set fire to the neighbor's trash can. The child's guardian states, "I can't believe anything that my child says!" The nurse should ID that the child's actions may be an indication of which disorder?

conduct disorder

True or false: medication adherence after the resolution of acute psychosis when taking an antipsychotic such as clozaril is not important

false

A nurse is educating a client who is prescribed clozapine. What common finding consistent with agranulocytosis should the nurse instruct the client to monitor for?

sore throat and muscle aches

A nurse is assessing a client who has paranoid personality disorder. Which of the following findings should the nurse expect?

suspiciousness of others

A nurse is caring for a client who ingested a SSRI and St. John's wort. True or false: dilated pupils and loss of muscle coordination are consistent with serotonin syndrome

true

True or False: a nurse is caring for a client who recently gave birth. the nurse notices the newborn is displaying manifestations of opioid w/d. The nurse should recognize the newborn's manifestations as signs of: neonatal abstinence syndrome

true

True or False: client's with anorexia nervosa can experience refeeding syndrome which can manifest with peripheral edema of both legs

true

True or false: a client with BPD is at high risk for self-harm after d/c from hospital?

true