PN Mental Health Practice A

A nurse is assisting with discharge planning for a client who needs to attend a day treatment center and has limited community and financial support. Which of the following referrals should the nurse recommend including in the client's discharge plan? A. Social worker B. Recreational therapist C. Psychologist D. Pharmacist

A. Social worker

A nurse is caring for a client who is 2 days postop following a hip arthroplasty. When a news report about military action appears on the television, the client says to the nurse . "My youngest child died 6 months ago while serving in the military." Which of the following responses should the nurse make? Select all the apply A. This must be a very difficult time for you B. Your child's death must be a terrible loss C. Its just awful what is going on in the world D. You need to focus on getting better E. Tell me something you remember about your child

A. This must be a very difficult time for you B. Your child's death must be a terrible loss E. Tell me something you remember about your child

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following findings should the nurse expect? A. Hypotension B. Bradycardia C. Hypothermia D. Pupillary dilation

D. Pupillary dilation (The nurse should expect a client who is experiencing opioid withdrawal to have dilated pupils. Constriction of pupils is caused by anoxia. When clients begin the withdrawal process, the pupils relax, causing dilation to occur. These findings will gradually diminish over 5 to 10 days)

A nurse is assisting with the planning of an interprofessional care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interprofessional treatment team should the nurse include? A. Occupational therapist B. Physician assistant C. Nurse researcher D. Dietitian

D. Dietitian

A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statements should the nurse include in the teaching? A. "The voices you been hearing should decrease" B. "You will likely have more energy while on this medication" C. "You should now be able to spend more time in the sun" D. "Call your provider immediately if you develop a dry mouth"

A. "The voices you been hearing should decrease"

A nurse is collecting data from a newly admitted client. Which of the following questions should the nurse include to gather psychosocial information? A. "Do you have a hobby that you enjoy?" B. "What is the data and where are you living?" C. "How are an apple and orange alike?" D. "Can you take this pencil and put it in the cup?"

A. "Do you have a hobby that you enjoy?"

A nurse is reinforcing teaching with a newly admitted client who has generalized anxiety disorder. Which of the following statements should the nurse make? A. "We will demonstrate for you to use relaxation techniques' B. "Someone will be here to work with you experience flashbacks." C. "Aversion therapy will be used to decrease your anxiety level." D. "Response prevention therapy will help you control your impulses

A. "We will demonstrate for you to use relaxation techniques'

A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence? A. A nurse does not notify the provider of a change in condition for a client who has schizophrenia B. A nurse delegates an assistive personnel to sit with a client who has bulimia nervosa during mealtimes C. A nurse administers an anti-anxiety medication to a restless client who has given implied consent D. A nurse does not document the completion of an incident report about a recent fall in the client's medical record

A. A nurse does not notify the provider of a change in condition for a client who has schizophrenia (Negligence is the failure to act in a manner which follows the standard of care. The nurse should inform the provider of any changes in a client's condition. Failure to do so is considered negligence)

A nurse is assisting with the admission of a client who has schizophrenia. Which of the following actions should the nurse take first? A. Conduct an abnormal involuntary movement scale test B. Discuss behavioral expectations with the client C. Orient the client to unit routines D. Encourage the client to attend group sessions

A. Conduct an abnormal involuntary movement scale test (The first action the nurse should take when using the nursing process is to collect data. The abnormal involuntary movement scale (AIMS) test is a data collection tool used to guide medication therapy for clients who are prescribed antipsychotic medications. Therefore, the first action the nurse should take is to conduct the AIMS test.)

a nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include in the plan to address limit setting? A. Establish and explain consequences for the client's behavior B. Teach the client to use reaction formation for behavior control C. Recommend that the client attend assertiveness training D. Encourage the client to increase socialization

A. Establish consequences for the client's behavior (The nurse should communicate desired behavior and expectations as well as detailed consequences for not meeting those expectations to a client who has borderline personality disorder. These expectations and consequences should be included in the plan of care when addressing limit setting with the client

A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following findings is an indicator of the client's use of this substance? A. Hypertension B. Drowsiness C. Bradycardia D. Constricted pupils

A. Hypertension

A nurse is organizing care for a group of clients. According to Maslow's hierarchy of needs, which of the following should the nurse plan to perform first? A. Offer finger foods to a client who is in the manic phase of bipolar disorder B. Document the affect of a client who had light therapy for seasonal affective disorder 2 days ago C. Assist a client who has a depressive disorder with decision making regarding group activities. D. Reinforce teaching about a new prescription of clozapine with a client who has schizophrenia

A. Offer finger foods to a client who is in the manic phase of bipolar disorder (When using Maslow's hierarchy of needs, the nurse should determine that the priority action is to address a client's physiological needs. By offering finger foods the nurse allows the client to eat while in motion, which helps to meet the client's daily calorie requirements.)

A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few moments later, the client cheerfully states, "Now, here is my favorite social worker!" The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Dissociation C. Denial D. Projection

A. Reaction formation (The nurse should identify that this client is using reaction formation. This is the defense mechanism in which the client is unable to process unacceptable feelings or behaviors and expresses the opposite to decrease anxiety.)

A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse take first? A. Remove harmful objects from the client's room B. Decrease the client's environmental stimuli C. Administer an antipsychotic medication to the client D. Provide physical activities for the client

A. Remove harmful objects from the client's room

A nurse is caring for a client in a day treatment program. Which of the following actions should the nurse take? A. Request transport for the client to an emergency department. B. Place a hypothermia blanket on the client C. Discontinue the client's fluoxetine therapy immediately D. Implement droplet precautions for the client

A. Request transport for the client to an emergency department

A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions? A. "For the first step of my therapy, I will look at pictures of cars." B. "I will snap a rubber band on my wrist when I feel anxious about riding in a car" C. "My therapist will be with me ride in a car together" D. "I will ride in a car for several hours at a time

B. "I will snap a rubber band on my wrist when I feel anxious about riding in a car"

A nurse is caring for a client who has anxiety disorder and is refusing to take a medication. Which of the following responses should the nurse make? A. "This medication is safe for you to take" B. "You have the right to refuse the medication" C. "You are presenting a risk to the other clients" D. "This medication is part of your treatment plan"

B. "You have the right to refuse the medication"

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect? A. Amenorrhea B. Dental caries C. Lanugo D. Yellow skin

B. Dental caries

A nurse is caring for an adult client who has injuries as a result of partner violence. Which of the following actions should the nurse take? A. Insist that the client report the incident to the authorities before beginning treatment B. Encourage the client to develop a safety plan C. Recommend that the partner remain in the room during the interview with the client D. Advise the client to obtain an order of protection from the court

B. Encourage the client to develop a safety plan (The nurse should encourage the client to develop a safety plan to aid in escaping further violence if necessary)

A nurse is monitoring the nutritional status of a client who has bulimia nervosa. The nurse should monitor the client for which of the following complications? A. Hyperchloremia B. Hyponatremia C. Decreased bone density D. Increased WBC count

B. Hyponatremia (The nurse should monitor clients who have bulimia nervosa for hyponatremia, which results from purging, vomiting, and laxative and/or diuretic use)

A nurse in a mental health facility is caring for a client who is becoming agitated. Which of the following actions should the nurse take first? A. Place the client in seclusion B. Offer diversionary activities C. Administer haloperidol D. Apply wrist restraints

B. Offer diversionary activities

A nurse in a provider's office is collecting data from an older adult client whose adult child reports that the client "seems confused and can't seem to remember much." Which of the following findings should lead the nurse to suspect delirium? A. The client's confusion worsens during times of stress B. The client's level of consciousness changes during the interview C. The client's confusion improves in the evening D. The client has a flat affect during the interview

B. The client's level of consciousness changes during the interview

A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client's confidentiality? A. The nurse documents subjective data about the client's condition in the client's medical record B. The nurse places the client's diagnosis on the whiteboard in the client's room C. "The nurse faxes the client's allergies to the pharmacy" D. The nurse reports threats that the client made to harm their partner to the provider

B. The nurse places the client's diagnosis on the whiteboard in the client's room

A nurse in an inpatient unit is assisting with a group therapy session. During the session, a client begins to shout and use aggressive language. Which of the following statements should the nurse make to the client? A. Why do you feel the need to speak this way to others in the group B. When you raise your voice, it makes me feel uncomfortable and unsafe C. You are frightening others in the group when you show your anger D. Why are you attending group therapy but not respecting the feelings of others?

B. When you raise your voice, it makes me feel uncomfortable and unsafe

A nurse is collecting data from a client who has bipolar disorder and a history of mania. Which of the following findings should the nurse identify as an indication that the client is relapsing? A. weight gain B. pressured speech C. Ritualistic behavior D. Anhedonia

B. pressured speech (The nurse should identify that rapid or pressured speech, provocative behavior, and insomnia are indications of potential relapse in a client who has bipolar disorder and a history of mania)

A nurse is reinforcing teaching with the parent of a child who has ADHD and is exhibiting disruptive behaviors at home. Which of the following actions should the nurse instruct the parent to take? A. Avoid enforcing a strict schedule for the child at home B. Use biofeedback with the child C. Give the child a PRN dose of methylphenidate D. Initiate a point system for the child

D. Initiate a point system for the child (The nurse should instruct the parent to use tokens or pints to reward desired behaviors and reduce maladaptive behaviors. A point system provides an incentive for the child to increase acceptable behaviors)

A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statements should the nurse make to gather information about the client's ability to think abstractly? A. "Subtract 7 from 100 and then continue subtracting 7 from each answer" B. "What do you think about when you are angry?" C. "How is an orange similar to an apple?" D. "Tell me about a vacation you took when you were a child."

C. "How is an orange similar to an apple?"

A nurse is caring for a client who gave birth to a stillborn fetus 1 week ago. The client states to the nurse, "I am so angry that my doctor didn't take better care of me and my baby." Which of the following responses should the nurse make? A. "You should concentrate on feeling better. You've been through a lot" B. "You should begin to accept what happened, so you can work through your loss." C. "It is important to share what you are feeling, even if it is anger." D. "Everyone experiences anger at first. This will pass over time"

C. "It is important to share what you are feeling, even if it is anger."

a nurse is assisting with screening a group of clients for major depressive disorder. The nurse should identify that which of the following clients is at an increased risk for the development of MDD? A. A client who is newly employed B. A client who abstains from alcohol C. A client who just gave birth D. A client who has been married for 15 years

C. A client who just gave birth (Clients who just gave birth or are in the early postpartum period are at an increased risk for developing MDD or postpartum depression)

A nurse observes a client who has schizophrenia and exhibits akathisia. Which of the following interventions should the nurse implement? A. Provide a handkerchief to the client to wipe excess saliva B. Initiate seizure precautions C. Administer an antiparkinsonian agent D. Implement emergency measures

C. Administer an antiparkinsonian agent (the nurse should anticipate that an antiparkinsonian agent will be administered for akathisia, which is an adverse effect of an antipsychotic medication for the treatment of schizophrenia)

A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findings is referred to as a negative symptom of schizophrenia? A. Delusions B. Echolalia C. Apathy D. Paranoia

C. Apathy (Negative symptoms of schizophrenia are deficits in the client's ability to experience emotions. Apathy is a negative symptom of schizophrenia that is manifested by a loss of interest in one's surroundings)

A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? A. Call for assistance to place the client in restraints B. Administer a sedative to the client C. Determine the client's intentions D. Place the client into the assigned seclusion room

C. Determine the client's intentions

A nurse is reinforcing teaching with a client whose provider has prescribed electroconvulsive therapy (ECT). Which of the following information should the nurse include? A. The client will receive continuous oxygen during the electrical stimulation intervals B. A benzodiazepine will be administered prior to the procedure C. ECT is an option for client after medication has been unsuccessful D. Confusion is expected for the first 2 days

C. ECT is an option for client after medication has been unsuccessful (Medication is the first-line of treatment for depression. ECT is prescribed when medication has been unsuccessful)

A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider? A. Inability to make decisions B. Anhedonia C. Feelings of hopelessness D. Fatigue

C. Feelings of hopelessness (When using the urgent vs. nonurgent approach to client care, the nurse should identify that feelings of hopelessness indicate that this crisis is at risk for suicide. Therefore, this is the priority findings for the nurse to report to the provider)

A nurse is contributing to the plan of care for a client who has bipolar disorder. Which of the following actions should the nurse include to promote a therapeutic environment during the working phase of the nurse-client relationship? A. Establish rapport B. Explain confidentiality and privacy C. Reinforce teaching about medications D. Specify a contract

C. Reinforce teaching about medications

A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder and continually washes their hands. Which of the following interventions should the nurse recommend including in the plan? A. Inform the client that excessive handwashing is a negative behavior B. Do not allow the client to use a private restroom C. Schedule times for the client to wash their hands during the day D. Explain that unit privileges will be taken away if excessive handwashing continues

C. Schedule times for the client to wash their hands during the day (Providing a schedule is a type of response prevention and can decrease anxiety by allowing the client to know in advance when handwashing can be performed)

A nurse in a long term care center is caring for an adult client who has Alzheimer's disease and whose partner died several years ago. The client appears upset and asks the nurse when their partner will visit again. The nurse states, "It seems like you are feeling lonely. Let's take a walk outside and talk." Which of the following communication strategies is the nurse using? A. Reminiscence therapy B. Feedback C. Validation Therapy D. Reflecting

C. Validation Therapy

A nurse is preparing to administer clozapine for the first time to a client who has schizophrenia. The nurse explains the therapeutic and adverse effects of the medication to the client prior to administration. Which of the following ethical concepts is the nurse demonstrating? A. Autonomy B. Justice C. Veracity D. Confidentiality

C. Veracity (Veracity is the duty to tell the truth. The nurse should uphold this ethical principle when administering a new medication to a client by explaining the therapeutic effects as well as the adverse effects. This action promotes a trusting relationship between the nurse and the client, which enhances the nurse's primary commitment to the client of providing optimum, quality care.)

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "This medication can cause dependence" B. "I'll take an extra dose of my medication when i start to feel anxious" C. It's important to take my medications 30 mins before bedtime." D. "I should expect my symptoms to improve in about 2 to 4 weeks"

D. "I should expect my symptoms to improve in about 2 to 4 weeks"

A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statements indicates an understanding of the information> A. "I can expect my cigarette cravings to go away within 7 to 10 business day" B. "I will likely fell like my heart is racing even when I'm resting" C. "I should increase my intake of calories because of the expected weight loss" D. "I will probably feel irritable within 24 hours of my last cigarette"

D. "I will probably feel irritable within 24 hours of my last cigarette"

A nurse is caring for an older adult client who is about to undergo screening with the mental status examination (MSE). The client asks about the purpose of this test. Which of the following responses should the nurse make? A. "We're just going to ask you some very simple questions" B. "This test will collect information about your family" C. "You are going to be okay. There is nothing to worry about" D. "This test will give us information about how you remember things"

D. "This test will give us information about how you remember things" (The MSE tests the cognitive function of the client. It is an assessment of the client's current memory, speech, and cognition.)

A nurse in an inpatient unit is collecting data from a group of clients. Which of the following findings should the nurse report to the provider? A. A client who has schizophrenia is using neologisms B. A client who has bipolar disorder is experiencing flight of ideas C. A client who has depression avoids making eye contact D. A client who has borderline personality disorder is pacing restlessly

D. A client who has borderline personality disorder is pacing restlessly (The nurse should identify that a client who has borderline personality disorder and is pacing restlessly is at increased risk for violence towards themselves or others. This behavior should be reported to the provider)

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A. Increased yawning B. Bradycardia C. Hypersomnia D. Diaphoresis

D. Diaphoresis

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include to improve the client's nutritional status? A. Weigh the client at the same time every other day B. Encourage the client to eat meals in the dining room with other clients. C. Request that the client keep a detailed food and beverage diary each day D. Have finger foods available for the client in a quiet area

D. Have finger foods available for the client in a quiet area (The nurse should offer finger foods to the client in a quiet area to increase the client's nutritional intake. Because the client is moving and active, they are more likely to consume foods that they can eat quickly, which will improve the nutritional status of the client.)

A nurse is caring for a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following client statement indicates the medication is effective? A. Naltrezone B. I get flushed when i drink alcohol while taking naltrexone C. Naltrexone decreases my fine hand tremors D. I drink less alcohol in a day while taking naltrexone

D. I drink less alcohol in a day while taking naltrexone

A nurse is developing countertransference toward a client during the working phase of the nurse-client relationship. To correct the situation, which of the following actions should the nurse take? A. Tell the client how to change their behavior B. Talk to the client about the developing feelings C. Ask to be reassigned to a different client D. Identify personal response to the client

D. Identify personal response to the client (Countertransference in an emotional response toward the client by the nurse. This response might be related to the nurse's past unresolved feelings or relationships. These findings can interfere with the nurse-client therapeutic relationship. In order to correct the situation of countertransference, the nurse must recognize personal reactions to the client in an attempt to work through these feelings)

A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? A. Preoccupied with perfectionism B. Uses attention-seeking behavior C. Exploitative of others D. Projects blame onto others

D. Projects blame onto others (The nurse should expect clients who have paranoid personality disorder to project blame onto others rather than taking responsibility for their own actions)

A nurse is attempting to establish a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? A. Summarize the goals achieved in the relationship B. Plan for the initial interaction with the client C. Establish the parameters of the relationship D. Promote the development of problem-solving skills

D. Promote the development of problem-solving skills