Psych Midterm

The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning their head as if listening to another person. The nurse assesses this behavior as indicating that the client is experiencing auditory hallucinations. What statement by the nurse is most appropriate?

"Are you hearing something?"

The client tells the nurse, "I'm frightened about my surgery tomorrow." What response by the nurse is best?

"Can you tell me what frightens you?"

The client with mania attempts to hit the nurse. Which is the best response by the nurse?

"Do not swing at me again. If you cannot control yourself, we will help you."

When conducting a focused assessment on a newly admitted client who attempted suicide, which question should the nurse include to ensure the client's safety? Select all that apply.

"Do you still have a plan to harm yourself?" "Have you ever tried to hurt yourself before?" "Are you willing to tell us if you plan to harm yourself again?"

When talking with the spouse of a client who attempted suicide, the psychiatric nurse demonstrates understanding of the priority areas of assessment by asking which questions? Select all that apply.

"Does your spouse harm himself or herself physically when stressed?" "Has your spouse attempted to kill himself or herself by injuring him- or herself."

A client who is hospitalized with depression tells a nurse, "I don't want to take the medication because I'm afraid I'll become suicidal." Which response by the nurse would be most appropriate?

"Have you ever thought about hurting yourself?"

The family of a 22-year-old client with bipolar disorder is having difficulty coping with the client's rapid mood swings, irritability, grandiose delusions, and overly intrusive behaviors. Following a visit to the unit, the parents discuss their frustration and anger with the nurse and ask what they should do to help the client. Which reply by the nurse is most appropriate?

"Help the client monitor medication adherence and watch for changes in mood and sleep."

The nurse is working with a client who is experiencing a crisis due to a divorce. Which statement would alert the nurse to the client's need for referral for further mental health counseling?

"I am trying to work through this but have had to cut myself a few times."

If a client states, "I carry this lucky rabbit's foot for luck, my dad did too, and it really works," which statement by the nurse reflects respect for the client's belief?

"I can accept that you feel it is lucky, so let's get to our activities for the day."

A client approaches the nurse and loudly states, "I'm not putting up with this anymore!" The most appropriate response by the nurse would be what?

"I can see you are angry. Tell me what's going on."

A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which is the most therapeutic response by the nurse?

"I don't hear the voice, but I know you hear what sounds like a voice."

During a night shift, a hospitalized client with depression tells a nurse that the client is going to kill himself or herself. The client is placed on constant observation. When the client asks to use the toilet, the nurse follows the client into the bathroom. The client says, "You don't need to follow me into the bathroom. Give me some space." Which response by the nurse is most appropriate?

"I must stay with you until we are sure you will not hurt yourself."

A client with schizophrenia is attending a follow-up appointment at the community mental health clinic. The client reports to the nurse, "I stopped taking the antipsychotic medication because I can't get an erection with my girlfriend anymore." Which should the nurse recommend to enhance the client's well-being?

"It is important for you to take an antipsychotic medication, but perhaps a different type will be less likely to affect your sexual functioning. I would like to call your health care provider about this."

A nurse is interacting with a client who is expressing feelings about the client's child's insensitive behavior. Which statement made by the nurse indicates the nurse is empathizing with the client? Choose the best answer.

"It sounds like this is very difficult for you, I can see why it causes you stress."

A nurse is meeting with a client prior to discharge from the hospital. The client tells the nurse he is "really worried about returning home." Which response indicates the nurse is employing therapeutic communication?

"Please share with me what is worrying you right now."

A client who is manic states, "What time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?" Which response by the nurse would be most appropriate ?

"Please slow down. I'm not sure what you need first."

A client states, "I am dead. I have come back from the dead." What is the most appropriate response by the nurse?

"Show me what you did in art therapy this morning."

An 80-year-old client with Alzheimer's disease is prescribed donepezil. Which teaching points should the nurse provide to the client's spouse about the new medication?

"The drug won't cure the client's Alzheimer's, but it has the potential to slow down the progression of the disease."

After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive?

"What could you have done when you first started to feel angry?"

A client with schizophrenia is reluctant to take prescribed oral medication. Which is the most therapeutic response by the nurse to this refusal?

"What is it about the medicine that you don't like?"

A client with a persecutory delusion has been explaining to the nurse the specifics of the conspiracy against the client. The client pauses and says, "I get the feeling that you don't actually believe that what I'm telling you is true." How should the nurse respond?

"What you're telling me is difficult for me to believe. This may be real for you, but not me."

A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client's confidentiality if the client states:

"When I get out of here, I'm going to kill my neighbor."

Which clients would be most likely to attempt situational suicidal thoughts?

A client who has been given a diagnosis of cancer with a poor prognosis

A nurse is caring for clients who are psychologically abused. Which clients should the nurse screen for psychological abuse? Select all that apply.

A partner of a client who has destroyed the front door of their home. A client whose partner is monitoring the amount of money spent on food and clothing. A partner of client who does not want the client to spend any time with family or friends. A parent of a client who is threatening to injure the family's pet.

A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time?

Accompany the client to his or her room to get dressed.

Which drug classification is the primary medication treatment for schizophrenia?

Antipsychotics

A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?

Approximately 2 weeks after starting antidepressant medication

The nurse is planning care for a client who has been newly diagnosed with a mental illness. Which should be the nurse's first step in managing this client's nursing care?

Assessment

During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling the client to do anything harmful. The nurse documents that the client is experiencing what?

Auditory hallucinations

A nurse is working in a psychiatric-mental health facility. The nurse observes a client pacing and punching the wall. Which measure can the nurse take for personal safety?

Avoid being alone with the client.

A client who has been prescribed fluoxetine for depression and has just had the dosage increased comes the emergency department. The nurse suspects serotonin syndrome based on which assessment?

Change in mental status Ataxia Diaphoresis Fever

The client stated, "I was so upset about my sister ignoring me when I was talking about being ashamed." Which nontherapeutic communication technique would the nurse be using if the nurse stated, "How are your stress reduction classes going?"

Changing the subject

A nurse suspects that a client has overdosed on the prescribed tricyclic antidepressant. Which assessment findings would support this suspicion? Select all that apply.

Confusion Hallucinations Agitation

A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?

Decrease the client's environmental stimuli.

A client states, "I'm worthless, and I don't deserve to live." This theme in the client's expressed thought may signal a maladaptive response to which disorder?

Depression

Before a client became depressed, the client was an active, involved parent with three children, often attending school functions and serving as a volunteer. The client is hospitalized for a major depressive episode and now reveals feeling like an unnecessary burden on the family. Which nursing diagnosis is most appropriate?

Disturbance of self-concept related to feelings of worthlessness

A client is being discharged on lithium. The nurse encourages the client to follow which health maintenance recommendations? Select all that apply.

Drink a 2 L bottle of decaffeinated fluid daily. Do not alter dietary salt intake. See the doctor if the client gets the flu.

Which is the most important skill the nurse must bring to the therapeutic nurse-client relationship?

Empathy

When preparing to educate a client regarding a newly prescribed antipsychotic medication, which action would be most appropriate for the nurse to do? Select all that apply.

Encourage the use of sugar-free gum to help manage dry mouth Suggest methods to minimize the potential for weight gain Identify lifestyle adjustments that the resulting lethargy may require Advise the client to discuss any concerns regarding sexual dysfunction

During an interview, the nurse has asked a client with depression about any hopes or plans for the future. In response, the client silently made a gesture of drawing the index finger from one side of the client's throat to the other. The nurse has informed the client that this must be communicated to the care team. What is the main rationale for the nurse's action?

Ensuring the client's safety

Initially, the nurse should focus on successfully achieving which goal in order to effectively provide care for a client diagnosed with a mental illness?

Establishing trust and rapport with the client

A nurse is assessing a client with bipolar disorder who is experiencing mania. The client states, "I'm just so beautiful. Everyone just stops and stares at how gorgeous I am. People constantly want to have sex with me." The nurse interprets these statements as indicative of which type of mood?

Expansive

The nurse who is developing a suicide prevention strategy would need to ensure which step is included?

Figuring out who is at risk for suicide Determining imminent risk of suicide Using assertive interventions if there is a threat of suicide Following up with interventions to prevent suicide in the future

A married couple arrives at the outpatient clinic. Upon assessment, the nurse finds that the couple believes that the police have been following them and tapping their phones for 2 months. This couple most likely suffers from which disorder?

Folie à deux

A client is being transferred from a group home to an evolving consumer household. The goal of this transition is for the client to eventually do what?

Fulfill daily responsibilities without supervision.

During a session with a client, the client asks the nurse what the client should do about the client's "cheating" spouse. The nurse replies, "You should divorce. You deserve better than that." The nurse used which nontherapeutic communication technique?

Giving advice

Which meal would the nurse provide to best meet the nutritional needs of a client who is manic?

Ham sandwich, cheese slices, milk

To care for an acutely suicidal client, which is the most effective initial mode of treatment?

Inpatient care

An aggressive client gets hold of a glass piece and prevents anyone from entering the room. What interventions should the nurse perform to ensure safety of the client, staff, and other clients? Select all that apply.

Leave the area immediately Summon help from others Shift other clients to a safe place

A client is exhibiting signs of mild delirium such as occasional confusion about why the client is in the hospital and what day of the week it is. When developing a care plan, the nurse identifies several strategies to improve the client's cognitive function. Which intervention will be helpful to the client?

Make up a daily calendar with the date and the times of scheduled activities.

A client suffers from drug-induced parkinsonism. The nurse notices this client walking with a shuffling gait. What other symptoms might this client show? Select all that apply.

Masklike facies Cogwheel rigidity Drooling Akinesia

A client on a medical unit has a comorbid diagnosis of depression and has been taking mirtazapine for several months prior to the current admission. When providing care to the client, which action would be most appropriate for the nurse to do? Select all that apply.

Monitor the client's mood and affect over the course of the admission. Ensure that the client is not cheeking or stockpiling the medication.

A client presents to the emergency department with a flat affect. The nurse suspects the client may be experiencing a major depressive episode. Which variable would the nurse need to keep in mind as representing the highest risk for this condition? Select all that apply.

Mood disorder in first-degree relatives Substance abuse Divorced

The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, "I saw you sitting alone and thought I might keep you company." The client turns away from the nurse. Which would be the most therapeutic nursing intervention?

Move to a chair a little further away and say, "We can just sit together quietly."

Which type of service is provided to medically stable clients who do not require inpatient, residential, or home care environments?

Outpatient care

A nursing student is preparing to care for a client diagnosed with schizophrenia. When interacting with the client, the student notices that the client is highly suspicious and guarded, stating, "They're out to get me." The student identifies this as what?

Paranoia

While conducting a mental status examination, the client accuses the nurse of recording the interview so that it can be sent to the Federal Bureau of Investigation. What type of delusion is this client experiencing?

Paranoid

The client is a 32-year-old diagnosed with bipolar disorder. The client attends group therapy for 6 hours a day and then returns home to the client's residence. In which setting would the client receive this type of care?

Partial hospitalization program

In clients who do not completely recover from being victimized by rape, which mental illness is most likely to develop?

Post-traumatic distress syndrome

A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to the client's feelings of sadness and hopelessness, the nurse would likely assess which physiologic symptoms of depression?

Psychomotor retardation and poor appetite

A nurse is preparing to administer pharmacotherapy as part of the treatment plan for a client with bipolar disorder. The nurse understands that this therapy is designed to achieve which goal? Select all that apply.

Rapid control of symptoms Decreased frequency of manic episodes Prevention of future episodes Decreased severity of manic episodes

A client is brought to the emergency department stating, "I'm scared because the Federal Bureau of Investigation is now tapping my home phone, and I can hear them talking between my two telephones during the night." The client's eyes dart around the room while the nurse is trying to interview the client, and the client is tapping the client's fingers on the table. The nursing priority with this client is what?

Reassure the client that the client is in a safe place where the client will be helped.

The client feels that the client's rights have been violated. Placing a client in restraints before using other methods of intervention violates which of the client's rights?

Receive treatment in the least restrictive environment

The client says to the nurse that the client is having trouble keeping up with things. The nurse is assessing a client with early signs of dementia. What is the nurse trying to determine when asking what the client ate for breakfast that morning?

Recent memory

When intervening with a suicidal client, the initial goal is to keep the client safe. Measures to optimize safety would include what?

Remove access to the means to attempt suicide

A client with Alzheimer's disease has a nursing diagnosis of risk for injury related to memory loss, wandering, and disorientation. Which nursing intervention should appear in this client's care plan to prevent injury?

Remove hazards from the environment.

The nurse documents that the client is exhibiting negative symptoms of schizophrenia when observing the client doing what? Select all that apply.

Repeatedly turning down invitations to join in unit activities Inability to maintain to complete a goal-directed activity

Which is the priority for admission to inpatient care?

Safety of self or others

A client with mental illness expresses interest in having a date with the nurse. Which would be the nurse's best response in this situation?

Set boundaries of a professional relationship.

A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?

Setting limits on aggressive and intimidating behavior

The nurse has used wrist and ankle restraints for a client who was extremely aggressive. What assessments should the nurse perform on a regular basis after restraining the client? Select all that apply.

Side effects of medication Peripheral circulation Skin condition Emotional well-being

A client has lost a job of 20 years. This is an example of which type of crisis?

Situational

A family member is the primary caregiver to a client with dementia. Which statement by the nurse would be most appropriate?

Spending some time relaxing and doing what you like to do will help you manage the demands of caregiving."

The ultimate goal of the treatment plan in inpatient care settings is what?

Stabilize the client

Which would be most important to assess and document in a client with depression?

Suicide risk

An aggressive client gets hold of a glass piece and prevents anyone from entering the room. What interventions should the nurse perform to ensure safety of the client, staff, and other clients? Select all that apply

Summon help from others Leave the area immediately Shift other clients to a safe place

A client comes to the clinic for an evaluation. During the interview, the client states that the client feels insects crawling all over the skin on the client's arms and legs. The nurse interprets this as which type of sensorium or processing deficit?

Tactile hallucination

A concerned family member tells the nurse, "I am concerned about my sibling. My sibling has been acting very different lately." Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the sibling has bipolar disorder?

Taking unnecessary risks

A client who has suspicion has been placed in a room with a roommate. The night nurse assesses the situation and reports that this client has been awake for the past 3 nights. The likely explanation for the client's wakefulness is what?

The client is fearful of what the roommate might do to the client while sleeping.

A client is hospitalized on a psychiatric unit secondary to a suicide attempt. The client has been diagnosed with depression and is consistently depressed. When assessing the client, which finding would alert the nurse that the client's suicidal risk has increased?

The client says the client feels better, with more energy to interact with others

Which nursing action would be a protective factor in the prevention of suicide for a client who has been identified at risk?

The nurse facilitates a referral to a drug and alcohol recovery program.

It is brought to the nurse administrator's attention that a nurse has developed an intimate relationship with a client. Which behavior indicates the nurse has engaged in an intimate relationship with a client?

The nurse is having dinner with a client outside the hospital premises.

A client with major depressive disorder is prescribed new drug therapy. To best the client's adherence to this therapy, which information would the nurse include in the teaching plan for the client? Select all that apply.

The possibility that two or more drugs will be prescribed The importance of staying in touch with mental health care provider The length of time treatment is anticipated A detailed description of possible side effects

What would be the most appropriate action by the student nurse when the client asked the student nurse to keep it a secret that the client plans to kill a family member?

The student nurse must tell the client that the student nurse cannot keep that secret and then report it to the instructor and/or staff members.

Which is one of the most common reasons clients are often concerned about confidentiality of treatment for mental health problems?

They are worried about the opinions of people who know them outside the hospital, due to shame produced by societal views of mental illness.

A nurse is preparing to assess a middle-aged client who was brought to the emergency department by the client's spouse. The spouse reports that the client has been "extremely depressed lately." When assessing this client, which would be a priority assessment?

Thoughts of self-harm

Which phase of the aggression cycle is defined as occurring when an event or circumstance in the environment initiates the client's response?

Triggering

A nurse tells a client that the nurse will come back in 10 minutes to reassess the client's pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing?

Trust

Nurses who work with children should be on alert for which physical signs of child abuse?

Unexplained cuts, bruises, burns, and scars

A client taking lithium for bipolar disorder comes to the clinic and reports symptoms which the nurse interprets as consistent with moderate lithium toxicity. Which action should the nurse perform? Select all that apply.

Withhold additional doses of lithium. Obtain a blood sample for lithium level. Push fluids. Contact the physician.

A client is being screened for clinical symptoms related to depression over the past 2 weeks. Which self-assessment screening instruments would be most appropriate?

Zung Self-Assessment Scale

The nurse suspects that a client is a victim of intimate partner violence. What should the nurse consider when caring for this client? Select all that apply.

availability of support support can be accessed safely

When assessing a client's potential for aggression and violence, which would the nurse identify as the most important predictor?

client's history

With a client who is aggressive with a potential for violence, which item would the nurse want to limit or remove from the breakfast tray?

coffee

A 22-year-old client has been manipulative of staff and disruptive in the milieu. Although the client is not dangerous to the client or others, the client has created problems on the unit and clearly is not making progress. The nurses offer prescribed medication, but the client consistently refuses "any drugs." The staff realizes that legally this client can ...

continue to refuse treatment.

A client diagnosed with delusional disorder is telling everyone that the client is the president of the United States. This client is exhibiting which type of delusion?

grandiose

What activity should be included in the first step of self-awareness?

identifying one's own values, attitudes, strengths and weakness

The nurse learns that a client has been receiving unwanted gifts and visits from someone in the neighborhood. For which unwelcomed behavior should the nurse plan interventions for this client?

stalking

A client was admitted to the intensive care unit after a motor vehicle accident. The client sustained a right parietal injury, resulting in an acute confusional state or delirium. The client reports that there are "bugs crawling around" on the arms. The nurse understands this as:

tactile hallucinations from delirium.

A client is being assessed after experiencing house damage from a tornado. Which client need would be a priority for the nurse to determine?

where the client will stay temporarily

A nurse is caring for a client who has been taking clozapine for 2 weeks. The client tells the nurse, "My throat is sore, and I feel weak." The nurse assesses the client's vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test?

white blood cell count