Psych 114

A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?

"I see you have done some grooming today

A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)

-Provide the client with small meals frequently Monitor the client's weight daily -Stay with the client during meals and for 1 hr afterward -Behavior prevent purging following food ingestion. -Offer specific privileges for sustained weight gain

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 private room in a quiet location on the unit

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

Assign a staff member to stay with the client at all times

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?

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

A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?

Explain that antidepressants often take several weeks to be fully effective.

A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?

Monitor for risk of self-harm.

A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

Preparing for artificial ventilation.

A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse's assessment priority?

Suidide risk

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?

Take the client outside and sit with her in the garden area.

A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?

illusions

A nurse is caring for a client who has schizophrenia and is experiencing hallucinations. The provider prescribes chlorpromazine 50 mg IM every 4 hr as needed. Available is chlorpromazine injection 25 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2

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?

Administer the morning dose of lithium.

A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports having discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the client's distress?

The client consumed alcohol while taking the medication.

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?

The client runs 4 miles outdoors every afternoon.

A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

"I understand that you are angry However, I followed the appropriate protocol."

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

"None of the kids at this school like me, and I don't like them either.

A nurse is teaching a client about adverse effects of zolpidem. Which of the following adverse effects should the nurse include in the teaching?

Daytime sleepiness

A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

Give the client extra time to communicate needs

A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?

Inspect the client's personal belongings.

A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?

Neuroleptic malignant syndrome

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?

Preventing self-directed violence.

A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?

Remain with the client for a while

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

Walk with the client at a gradually slowerpace

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

Welght gain