Passpoint

A more experienced nurse is attempting to help a newly hired nurse gain a better understanding of delusions. Which statement, provided by the experienced nurse, would correctly explain behavior that represents a client's delusion?

"A client tells you that the FBI is monitoring conversations through their IUD (intrauterine device)."

A client with stage 1 Alzheimer's disease is diagnosed with terminal lung cancer. The client wonders about "reaching the end" asks the nurse what to do. How should the nurse respond?

"An advance directive will help to make sure that your wishes are carried out."

A hospitalized client who cares for a parent with Alzheimer's disease at home reports feeling guilty because, at times, the client wishes the parent would die. When talking with the client, which response would be most appropriate?

"Being responsible for your father's care must be difficult."

The nurse is gathering data from a client with dissociative identity disorder (DID). What statement by the client would the nurse expect to hear?

"I can't recall certain events or experiences."

A client with a history of schizophrenia is having hallucinations. The client shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" Which response by the nurse would be best?

"I don't see them, but I know you believe you do."

A 54-year-old client who was admitted to the psychiatric unit during an acute phase of schizophrenia has hardly eaten and hasn't bathed or changed his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication adjustment. Which statement by the client indicates that he's ready for discharge?

"I know a sign of my disease is not bathing and maintaining my personal appearance."

A client is taking chlorpromazine as part of a treatment plan. Which response by the client indicates that the client understands the education about the drug?

"I need to schedule appointments for routine medication checks."

A client who has been taking imipramine, 125 mg P.O. daily, for 1 week wants to stop taking the medication because the client still feels depressed. Which response by the nurse would be mostappropriate at this time?

"Imipramine must build up to a therapeutic level; it may take 3 to 4 weeks to reduce depression."

A client with antisocial personality disorder says, "I always want to blow things off." Which response by the nurse is most appropriate?

"Let's work on considering some options and strategies."

Which statement, made by a client with paranoid personality disorder, shows that education about social relationships is effective?

"Sometimes I can see what causes relationship problems."

A client diagnosed with Alzheimer's disease (AD) tells the nurse that today a visitor is coming to have lunch. The nurse knows that the visitor isn't coming that day. Which response by the nurse would be most appropriate for this situation?

"Today is Monday, March 8, and we'll be eating lunch in the dining room."

One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic?

"You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy."

A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be appropriate?

"Your cursing is interrupting the activity. Take time out in your room for 10 minutes."

The nurse, obtaining data from a client on admission, suspects this client may be depressed. Which self-rating scale should the nurse have the client complete?

Beck and Zung

A 62-year-old male client with schizophrenia tells a nurse that he sexually molests his cousin. He tells the nurse that he's never told anyone and begs her to keep his secret. Which action should the nurse take?

Document the details of the conversation and notify the nursing supervisor.

Discharge instructions for clients receiving tricyclic antidepressants include which of following information?

Don't consume alcohol.

A client states to the nurse, "The voices are telling me to do terrible things." As part of the client's initial therapy, which action would be most likely included?

Find out what the voices are saying.

A client with major depression frequently is irritable, abrasive, and uncooperative and refuses to participate in group activities. When working with this client, the nurse should use which approach?

Firmness

The nurse is addressing discharge issues for a client who is hospitalized for a recent suicide attempt. How can the nurse best assure the safety of a client after discharge?

Include a detailed plan of action for the client to follow if he/she begins to experience suicidal thoughts.

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what severe complication of antipsychotic therapy?

Neuroleptic malignant syndrome (NMS)

A client gave birth to an infant 3 days ago and now does not know where she is, does not realize she has a child, and is hearing voices and seeing animals in her hospital room. What would the nurse do first?

Notify the health care provider (HCP).

A client chronically complains of being unappreciated and misunderstood by others. She is argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder?

Passive-aggressive personality

A 36-year-old client with a history of schizophrenia is admitted to the emergency department with a fever of 102° F (38.9° C), severe headache, photophobia, nuchal rigidity, and nausea. A physician believes that a lumbar puncture is necessary to help confirm his suspicions of meningitis. The nurse is asked to witness the informed consent. How can the nurse best assess the client's mental status before witnessing the consent?

Perform a brief mental status examination to determine whether the client is oriented to person, place, time, and purpose.

After an upsetting divorce, a client threatens to commit suicide with a handgun and is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client?

Risk for self-directed violence related to plans to commit suicide by handgun

A client who is diagnosed with borderline personality disorder has become attached to one nurse and refuses to speak with other staff members, claiming that they are mean, abusive, and are withholding medication. To address this behavior, which intervention would be most appropriate?

Rotate the nurses who are assigned to the client.

A client who wanders is admitted to a restraint-free facility. Which nursing interventions can be implemented to avoid restraint use? Select all that apply.

Schedule diversional activities. Take the client on daily walks. Place the client in a room close to the nurses' station.

A nurse is assigned to care for a client recently admitted to the psychiatric facility who has attempted suicide. When collecting data from the client, which action would be most appropriate at this time?

Search the client's belongings carefully for items that could be used to attempt suicide.

A client in the behavioral health unit with a history of noncoercive paraphilia is experiencing an auditory hallucination. What is the priority nursing action?

Stay with the client.

A client is diagnosed with somatic symptom disorder. What understanding should the nurse have regarding somatic symptom disorder when rendering care to this client?

Symptoms are real to the client, even though there may not be an organic etiology.

A nurse is caring for an older adult client with late-stage Alzheimer's disease. The client's spouse tells the nurse that the client has become very dependent, stating, "I feel guilty taking time for myself because the client cries out when I'm not present." When assisting with developing a plan for the client's spouse, which outcome would be most appropriate?

The caregiver distinguishes obligations that must be fulfilled and limit those that are unnecessary.

A nurse is caring for a client with a diagnosis of dissociative identity disorder (DID). Which client behavior should the nurse identify as a safety risk?

The client expresses a desire to do self harm.

The nurse is caring for a client with paranoid personality disorder. Which behavior observed by the nurse is documented as a sign of this disorder?

The client is afraid another person will inflict harm.

When reviewing a client's chart, the nurse sees the progress note. Which statement about the client's condition is most accurate?

The client may not be motivated to change their behavior or their lifestyle.

A client with a history of major depression established a psychiatric advance directive that was deemed legally valid. The directive specified that the client did not want electroconvulsive therapy (ECT) at any time. The client is legally competent and has expressed a renewed interest in trying ECT. The nurse should anticipate what event?

The client may revoke or amend the terms of the advance directive.

Teaching for women in their childbearing years who are receiving antipsychotic medications should include which of the following facts?

The client should continue using contraception during periods of amenorrhea.

A nurse caring for a client diagnosed with schizophrenia should perform which intervention when the client becomes suspicious and refuses to take their medication?

Wait for a short time and then attempt to administer the medication

The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which trait would the nurse be likely to uncover during data collection?

a low tolerance for frustration

The nurse observes a child with autism banging his or her head against the floor repetitively. Which nursing action is the priority?

apply a helmet on the child

A client who has just had electroconvulsive therapy (ECT) asks for a drink of water. Which intervention would be the nurse's priority?

assess the gag reflex

An adolescent who's depressed and reported by the parents as having difficulty in school is brought to the community mental health center to be evaluated. Which other health problem would the nurse suspect?

behavioral difficulties

The nurse is assisting with the development of a treatment plan for a client with a specific phobia. Which intervention should the nurse prepare the client for?

behavioral therapy

The nurse is obtaining data from a group of clients with depression. Which clients would the nurse recognize would most benefit from electroconvulsive therapy (ECT)?

clients who are severely depressed and do not respond to medication trials

A client with schizophrenia was admitted to the psychiatric unit during the night. The next morning, the client begins to call the nurse by a sister's name. Which intervention is best?

correcting the misidentification and orienting the client to the unit and staff

A nurse is frustrated by inability to make much progress establishing a therapeutic relationship with a client with bipolar disorder. The nurse's most professional response would be to:

discuss the situation with a more experienced peer.

A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority?

ensuring the safety of this client and other clients on the unit

Family members of a client with bipolar disorder tell the nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:

flight of ideas and inflated self-esteem.

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on time spent in bed during the day.

A nurse is caring for a client in the early stages of Alzheimer's disease (AD). Which client behavior will the nurse most likely observe?

inability to remember breakfast food

A client has depression after the death of a child. After a suicide attempt, the client is admitted to the inpatient psychiatric unit. During the admission interview, the client reports no longer wanting to die. Which action would be most appropriate for the nurse?

inspect the client's personal belongings for potentially dangerous objects

A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:

listen to a personal stereo through headphones and sing along with the music.

A nurse is carrying out the plan of care developed for a client diagnosed with dissociative identity disorder (DID). Which intervention would be the priority for this client?

maintaining consistency when interacting with the client

A nurse is caring for a client with borderline personality disorder. Which nursing intervention has priority?

maintaining consistent, realistic limits

The nurse is caring for a client with dementia. Which nursing action is the priority?

maintaining optimal physical health

The nurse is caring for a client immediately after the client has received electroconvulsive therapy (ECT) for the treatment of severe depression. What is a priority intervention for this client?

orient the client to the surroundings

A client with depersonalization/derealization disorder spends much of the day in a dreamlike state, ignoring personal care needs. What situation is this behavior most likely related to?

perceptual impairment

A client diagnosed with major depression states, "Everything is my fault, and I would be better off dead." Which priority intervention would the nurse implement?

place the client on suicide precautions

Which nursing intervention would help a client diagnosed with Alzheimer's disease (AD) perform activities of daily living?

provide ample time for the client to complete basic tasks

The nurse is reviewing the plan of care for a client diagnosed with schizophrenia who has just been admitted to the psychiatric unit. Which intervention would the nurse identify as the priorityfor this client?

providing a consistent, predictable environment

The nurse asks a client with a suspected dementia disorder to recall what was eaten for breakfast. What data is the nurse gathering from this client?

recent memory

An adolescent client with a diagnosis of schizophrenia has become very clingy and begins sucking their thumb while interacting with the nurse. The nurse understands that these behaviors indicate which defense mechanism?

regression

A confused client is brought to the emergency room. The client's has a heart rate of 108/minute and blood pressure 102/68 mm Hg. The family states the client has been taking lithium for manic episodes. Which laboratory results would be most concerning to the nurse?

sodium 150 mEq/L (150 mmol/L), hemoglobin 19.2 g/dL (192 g/L), blood urea nitrogen (BUN) 38 mg/dL (13.57 mmol/L)

Identify the four (4) findings most significant in the client's case which are essential to be addressed prior to client's discharge back to the community.

statement of wanting to "end it all" lack of healthcare/prescription benefits uncertainty in housing food insecurity

A nurse is reinforcing education for the parents of a teenage client about the warning signs of potential adolescent suicide. Which signs should the nurse include?

statements such as not being around much longer

A client with dissociative disorder is hospitalized. The client has threatened to commit suicide. When gathering data from the client, which set of circumstances would the nurse identify as indicating the highest risk of suicide?

suicide plan, handy means of carrying out plan, and history of previous attempt

A client with schizophrenia is admitted to the psychiatric unit of a hospital. Data collection should include careful observation of the client's:

thinking, perceiving, and decision-making skills.