Custom: Custom: Practice 7(Mental Health)

A nurse is working with a client who is displaying disproportionate fear of having cancer. The nurse notes the client is seeking out medical care more frequently, has high anxiety, and believes they have cancer, despite no medical evidence to support this. Which of the following disorders is the client likely experiencing? Functional neurological symptom disorder Factitious disorder Illness anxiety disorder Somatic symptom disorder

Illness anxiety disorder Illness anxiety disorder is characterized by excessive worry about a medical disorder.

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, "I am not sure why I need to have a relapse plan." Which of the following responses should the nurse make? "A relapse plan describes how you use coping strategies for living in the community." "A relapse plan explains how you can be hospitalized if needed." "A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse." "A relapse plan addresses your living, housing, and working needs."

"A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse." CORRECT A relapse plan is about recovery and should be developed with the client and health care team to help the client recognize signs of relapse and a plan for what to do if symptoms do occur or get worse. This plan empowers the client and aids in recovery.

A nurse is providing education to the family of a client who has Alzheimer's disease. Which of the following statements should the nurse make when explaining the role of acetylcholine in this disease process? "Acetylcholine plays a central role in findings of Alzheimer's disease." "Acetylcholine is an excitatory neurotransmitter that is responsible for learning and memory." "Acetylcholine has minimal impact on sleep and muscle functioning." "Acetylcholine regulates the release of histamine and glutamate."

"Acetylcholine plays a central role in findings of Alzheimer's disease." The nurse should identify that individuals with Alzheimer's disease are found to have a decreased number of neurons that excrete acetylcholine, resulting in lower levels of acetylcholine. Acetylcholine regulates the sleep-wake cycle and is responsible for muscle functioning and helps with arousal, short-term memory, and learning.

A nurse is preparing a presentation about the relationship of genetics, stress, and developing mental illness. Which of the following information should the nurse plan to include in the presentation? "Mental health can be prevented by regular appointments with a health care provider." "Adoptive studies suggest that there is a genetic correlation between one's biological family and developing a mental illness." "Family studies show that mental health has no genetic association." "Twin studies support that stress is not related to mental illness."

"Adoptive studies suggest that there is a genetic correlation between one's biological family and developing a mental illness." CORRECT The nurse should identify that although most mental health disorders cannot be identified through genetic testing, research like family, adoptive, and twin studies support that there is correlation between developing a mental health disorder, genetics, and environmental factors.

A nurse is discussing treatment options with the guardian of a child who has been diagnosed with dissociative identity disorder. The guardian asks, "How is nursing care different for children diagnosed with dissociative identity disorder compared to adults?" How should the nurse best respond? "Usually, older clients have better treatment outcomes." "Usually, only adults are on psychiatric medication for this disorder." "Assessing for thoughts of self-harm is important, regardless of age." "Nursing interventions for this diagnosis are very limited, regardless of age."

"Assessing for thoughts of self-harm is important, regardless of age." Regardless of the client's age, assessing for thoughts of self-harm or suicidal ideation is a priority.

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, "My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?" Which of the following responses should the nurse make? "Do you think of yourself as more of an introvert? That makes a difference with how you socialize." "Were you avoiding your friend so that you could hear the voices more clearly?" "Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning." "That is very interesting, We are not sure why people start to isolate themselves."

"Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning." Social isolation has been identified as an early manifestation of psychosis. During this isolation the person often experiences negative thoughts, which may lead to other symptoms of psychosis, such as hearing voices.

A nurse is talking with the parent of a child who has a history of trauma and was just diagnosed with dissociative identity disorder. The parent states, "I don't think this is right, my daughter is just doing this for attention." Which of the following responses is the most therapeutic response? "Dissociation is a symptom that can be overlooked in children. Trauma can increase dissociation." "You're right; dissociative identity disorder is commonly overdiagnosed in children." "Why would your daughter do something like this for attention?" "Our physician is very capable of making an accurate diagnosis. I would trust their judgment."

"Dissociation is a symptom that can be overlooked in children. Trauma can increase dissociation." Dissociative identify disorder is characterized by the development of alternate personalities (alters) that have distinct personalities and behaviors. Childhood trauma is a significant risk factor for the development of this disorder.

A nurse is providing teaching to a newly licensed nurse who is caring for a client undergoing cognitive behavioral therapy for the treatment of aggression. Which of the following statements by the newly licensed nurse indicate an understanding of the teaching? "Families who live in low-income housing are at an increased risk for developing anger and aggression." "Smoking during pregnancy can place the child at an increased risk for developing anger and aggression." "Families who have financial hardships are at an increased risk for developing anger and aggression." "Clients who live in areas of high crime are at an increased risk for developing anger and aggression." "Clients who live in areas of high pollution are at an increased risk for developing anger and aggression." "Clients who live in suburban areas are at an increased risk for developing anger and aggression."

"Families who live in low-income housing are at an increased risk for developing anger and aggression" is correct. The nurse should recognize that monoamine oxidases (MAOs), specifically serotonin, are the neurotransmitters responsible for aggressive behavior. A link has been identified between deficient variations of the MAO-A gene and aggressive behavior, specifically an increase in 5-HT levels. This abnormality is called Brunner Syndrome, which is characterized by impulsivity, aggression, cognitive impairment, and violence. Other factors that contribute to the etiology of anger, aggression, and violence include cultural, socioeconomic, political, environmental, medical, and psychological. "Smoking during pregnancy can place the child at an increased risk for developing anger and aggression" is correct. The nurse should recognize that monoamine oxidases (MAOs), specifically serotonin, are the neurotransmitters responsible for aggressive behavior. A link has been identified between deficient variations of the MAO-A gene and aggressive behavior, specifically an increase in 5-HT levels. This abnormality is called Brunner Syndrome, which is characterized by impulsivity, aggression, cognitive impairment, and violence. Other factors that contribute to the etiology of anger, aggression, and violence include cultural, socioeconomic, political, environmental, medical, and psychological. "Families who have financial hardships are at an increased risk for developing anger and aggression" is correct. The nurse should recognize that monoamine oxidases (MAOs), specifically serotonin, are the neurotransmitters responsible for aggressive behavior. A link has been identified between deficient variations of the MAO-A gene and aggressive behavior, specifically an increase in 5-HT levels. This abnormality is called Brunner Syndrome, which is characterized by impulsivity, aggression, cognitive impairment, and violence. Other factors that contribute to the etiology of anger, aggression, and violence include cultural, socioeconomic, political, environmental, medical, and psychological. "Clients who live in areas of high crime are at an increased risk for developing anger and aggression" is correct. The nurse should recognize t

A nurse is preparing a presentation on neurotransmission. Which of the following statements about the neurotransmitter histamine should the nurse include? "Histamine is responsible for affective and cognitive functioning." "Histamine is essential to sleep and muscle functioning." "Histamine is partially responsible for level of consciousness." "Histamine is an excitatory neurotransmitter that is responsible for learning and memory."

"Histamine is partially responsible for level of consciousness." The nurse should identify that histamine regulates the release of histamine, glutamate, serotonin, and gamma amino butyric acid (GABA), which have an effect on alertness and wakefulness.

A nurse is providing care to a child during a routine wellness check-up. Which of the following client statements should indicate to the nurse that the client is at a higher risk for experiencing abuse and violence? "Sometimes I am not hungry when I wake up in the morning." "I usually do well, but I didn't get a good grade on my last test." "I don't really have any role models." "I think my parent is starting a new job this month."

"I don't really have any role models." Not being able to identify a role model is a risk factor for abuse and violence. Some other risk factors associated with abuse, aggression, and violence include a history of violence, witnessing abuse, and poor self-esteem.

A nurse is caring for a client who has a mental disorder. Which of the following statements by the client suggests the inability to process new information? "I feel like someone is watching me." "I am sad no matter how well things are going." "I have a difficult time remembering things." "I need to catch the bird that is flying in my room."

"I have a difficult time remembering things." This statement suggests that the client is unable to process new information. The inability to process new information is a cognitive symptom of schizophrenia.

A nurse is providing education about somatic symptom disorder to a client's family. Which of the following pieces of information should the nurse include in the education? "Somatic symptom disorder is characterized by suicidal ideations or thoughts of death." "There are limited effective treatment options for this disorder." "Individuals may intentionally make up the symptoms they are experiencing." "Individuals with somatic symptom disorder experience real physical effects, but these manifestations are due to emotional causes rather than physical ones."

"Individuals with somatic symptom disorder experience real physical effects, but these manifestations are due to emotional causes rather than physical ones." Somatization is when emotional distress and psychological issues are exhibited in physical manifestations that cannot be explained medically.

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. Which of the following statements should the nurse make to the client? "It is now time for you to bathe. Do you want to wear the red or green shirt?" "Do you really think it is ok not to bathe? What is going on with you?" "This is it! You are getting a bath! There are three of us here to bathe you!" "I'm going to ignore your lack of self-care because it is an aspect of the disorder."

"It is now time for you to bathe. Do you want to wear the red or green shirt?" This client appears to be having alterations in executive functioning as evident by lack of self-care. The nurse must be direct and consistent with expectations, communicating in a clear, calm, and concise manner while maintaining a therapeutic alliance with the client.

A nurse is caring for a client who is crying and states they are depressed and feel like they are "going crazy." Which of the following client statements indicates the client is experiencing emotional abuse? "My ex-partner tells me that I can't do anything right." "I suppose I really do need to be on medication, like my ex-partner said." "My ex-partner constantly makes fun of my weight." "My friend recently passed away." "I am newly divorced and a single parent." "I recently was promoted at work but now I'm unable to work with the same coworkers I was used to working with."

"My ex-partner tells me that I can't do anything right" is correct. The nurse should recognize that emotional abuse is the use of threats, insults, and intimidation to exert control over another person. Findings of emotional abuse include changes in usual behavior, becoming extremely withdrawn, noncommunicative, or nonresponsive, loss of self-esteem, nervousness around certain people, or an individual's report of emotional abuse or mistreatment. Emotional abuse can also include name-calling, humiliation, making someone feel guilty, and making someone think they are going crazy. "I suppose I really do need to be on medication, like my ex-partner said" is correct. The nurse should recognize that emotional abuse is the use of threats, insults, and intimidation to exert control over another person. Findings of emotional abuse include changes in usual behavior, becoming extremely withdrawn, noncommunicative, or nonresponsive, loss of self-esteem, nervousness around certain people, or an individual's report of emotional abuse or mistreatment. Emotional abuse can also include name-calling, humiliation, making someone feel guilty, and making someone think they are going crazy. "My ex-partner constantly makes fun of my weight" is correct. The nurse should recognize that emotional abuse is the use of threats, insults, and intimidation to exert control over another person. Findings of emotional abuse include changes in usual behavior, becoming extremely withdrawn, noncommunicative, or nonresponsive, loss of self-esteem, nervousness around certain people, or an individual's report of emotional abuse or mistreatment. Emotional abuse can also include name-calling, humiliation, making someone feel guilty, and making someone think they are going crazy.

A nurse is caring for a client who is having trouble managing anger and is upset because they feel their personal property is being disrespected. Which of the following client statements should the nurse recognize as being the cause of the client's anger and frustration? "My neighbor has not been coming to the neighborhood block meetings." "My neighbor has been letting their dog come into my yard every day to dig holes, bury bones, and go to the bathroom." "My neighbor goes out to get the mail right after I go out to get mine." "My neighbor watches all the neighborhood traffic from their front window."

"My neighbor has been letting their dog come into my yard every day to dig holes, bury bones, and go to the bathroom." The nurse should recognize that the tendency to be violent, angry, and aggressive can develop from many different mental illnesses. Violent behavior can occur when a person feels deceived, invalidated, frustrated, attacked, threatened, powerless, and or treated unfairly. These tendencies can also occur when people feel like their feelings or possessions are not being respected.

A nurse is caring for a client who has been admitted for a psychiatric evaluation after displaying aggressive behavior towards their partner and 2-year-old child. Which of the following client statements should the nurse identify as potentially contributing to aggression? "A family member took me fishing several times when I was a kid." "I drink a glass of wine occasionally with dinner." "My parent was physically abused as a child." "My parent used their fists to hit me as a child."

"My parent used their fists to hit me as a child." The nurse should recognize that risk factors that are associated with abuse, aggression, and violence include a history of violent behavior, being the target of a crime, a history of abuse or violence, a comorbidity of abuse, aggression and violence, low self-esteem, inadequate coping mechanisms, the lack of a positive role model as a child, and the presence of adverse childhood experiences (ACEs).

A nurse in an outpatient behavioral facility is caring for a client who has a substance use disorder and a history of violence. Which of the following client statements should the nurse identify as being consistent with adverse childhood experiences (ACEs)? "My parent would swear often at my sibling and I." "My parent went to prison when I was 12 years old." "My parents would get in physical altercations." "My parents divorced when I was 13 years old." "We always had plenty of food in the house to eat." "I was teased at school for wearing dirty clothes every day for weeks."

"My parent would swear often at my sibling and I" is correct. The nurse should recognize that ACEs are events that a child experiences before age 18 that might have been traumatic and could potentially affect them emotionally. These include experiencing abuse or neglect, experiencing some sort of violence, having a parent or sibling that is incarcerated, having parents that are separated, and having someone in the household who has a mental illness or experiencing substance use disorder. "My parent went to prison when I was 12 years old" is correct. The nurse should recognize that ACEs are events that a child experiences before age 18 that might have been traumatic and could potentially affect them emotionally. These include experiencing abuse or neglect, experiencing some sort of violence, having a parent or sibling that is incarcerated, having parents that are separated, and having someone in the household who has a mental illness or experiencing substance use disorder. "My parents would get in physical altercations" is correct. The nurse should recognize that ACEs are events that a child experiences before age 18 that might have been traumatic and could potentially affect them emotionally. These include experiencing abuse or neglect, experiencing some sort of violence, having a parent or sibling that is incarcerated, having parents that are separated, and having someone in the household who has a mental illness or experiencing substance use disorder. "My parents divorced when I was 13 years old" is correct. The nurse should recognize that ACEs are events that a child experiences before age 18 that might have been traumatic and could potentially affect them emotionally. These include experiencing abuse or neglect, experiencing some sort of violence, having a parent or sibling that is incarcerated, having parents that are separated, and having someone in the household who has a mental illness or experiencing substance use disorder. "I was teased at school for wearing dirty clothes every day for weeks" is correct. The nurse should recognize that ACEs are events that a child experiences before age 18 that might have been traumatic and could potentially affect them emotionally. These include experiencing

A nurse is providing education to a group of clients about the process of neurotransmission. Which of the following statements about neurotransmission should the nurse make? "Neurotransmitters are chemical components that allow neurons to store energy for future use." "Neurotransmitters are found throughout the body." "Neurotransmitters function by inhibiting the production of glucose." "Neurotransmitters are activated by the enzyme transferase."

"Neurotransmitters are found throughout the body." The body has a vast system of nerves composed of neurons, and this is where neurotransmitters are found. Neurotransmitters play a role in nearly every function of the body, including the brain. Specifically, neurotransmitters are chemical communicators carrying specific messages from one nerve cell to another and function as one of the main components of how the body communicates with itself.

A nurse is educating a newly licensed nurse about psychiatric pharmacogenomic testing. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "Psychiatric pharmacogenomic testing allows providers to determine the cause of mental illness based on genetics." "Psychiatric pharmacogenomic testing allows providers to determine effective treatment modalities." "Psychiatric pharmacogenomic testing allows providers to determine the likelihood that a treatment will produce a cure." "Psychiatric pharmacogenomic testing provides health care providers with information about treatment interactions."

"Psychiatric pharmacogenomic testing allows providers to determine effective treatment modalities." The nurse should identify that psychiatric pharmacogenomic testing may be utilized to determine the efficacy of certain medications based on a client's genetic profile.

A nurse is speaking with the parent of a client who is experiencing manifestations of psychosis. The parent states, "I don't understand how a child can experience psychosis." Which of the following responses should the nurse make? "Recreational drugs that block histamine receptors cause manifestations of psychosis." "Norepinephrine is a neurotransmitter that is primarily responsible for psychosis." "Psychosis may be experienced when an individual has excessive amounts of glutamate in the brain." "Low levels of acetylcholine in the brain may cause manifestations of psychosis."

"Psychosis may be experienced when an individual has excessive amounts of glutamate in the brain." The nurse should identify that high levels of glutamate could serve as a precursor for an individual developing manifestations of psychosis.

A nurse is providing mental health education to a group of high school students. Which of the following information about screening for mental illness should the nurse include? "Regular physical examinations are commonly used to diagnose mental illness." "Screening for mental illness is difficult because most mental illnesses cannot be detected through laboratory testing." "Risk factors for developing a mental illness are unknown, making screening difficult." "Mental illnesses can be detected through regular blood tests."

"Screening for mental illness is difficult because most mental illnesses cannot be detected through laboratory testing." The nurse should identify that most mental health disorders are not able to be detected through laboratory testing like blood work or medical imaging techniques.

A nurse is caring for a client who has a new diagnosis of somatic symptoms disorder. The nurse should identify that the client must have been experiencing manifestations of the disorder for how long before diagnosis? 6 months 1 week 3 months 4 weeks

6 months Manifestations must be present for 6 months before a diagnosis can be made. The manifestations must cause significant distress or interruption in daily functioning.

A nurse is reviewing treatment options for a client who has functional neurological symptom disorder. Which of the following treatments should the nurse identify as being most effective for this disorder? Systematic desensitization A combination of medication and psychotherapy Daily benzodiazepines to prevent new symptoms. Daily physical therapy

A combination of medication and psychotherapy The nurse should identify that a combination of medication and psychotherapy is often the most effective treatment for this disorder.

A nurse is reviewing treatment options for a client who has functional neurological symptom disorder. Which of the following treatments should the nurse identify as being most effective for this disorder? Systematic desensitization A combination of medication and psychotherapy Daily benzodiazepines to prevent new symptoms. Daily physical therapy

A combination of medication and psychotherapy The nurse should identify that a combination of medication and psychotherapy is often the most effective treatment for this disorder.

A nurse is caring for a client who has schizophreniform disorder. Which of the following manifestations should the nurse expect? A duration of symptoms from one to six months The addition of mood disorder symptoms A greater ability to distinguish between reality and symptoms Less intense and frequent symptoms

A duration of symptoms from one to six months The duration of the symptoms is shorter, from one to six months, when a client has schizophreniform disorder.

A nurse is preparing an in-service for a group of staff members about dissociative identity disorder. Which of the following should the nurse identify as a risk factor for this disorder? Borderline personality disorder A history of self-injurious behavior A history of schizophrenia History of trauma during the developmental years

A history of trauma is the most significant risk factor History of trauma during the developmental years History of trauma during developmental years is the biggest risk factor for dissociative identity disorder.

A nurse is providing care to a client who is aggressive and demonstrating self-injurious behaviors. Which of the following disorders does the nurse identify as being consistent with this behavior? Autism spectrum disorder Obstructed sleep apnea Insomnia Narcolepsy

Autism spectrum disorder The nurse should recognize that clients who have autism spectrum disorder (ASD) might demonstrate self-injurious acts, such as scratching, slapping, or biting themselves. Clients with ASD are more likely to demonstrate aggressive behavior when they feel they are threatened.

A nurse is caring for a 50-year-old client who is being evaluated for late-onset schizophrenia. Which of the following findings should the nurse expect? Used cannabis as teenager. Age of 50 years A change in personality Family member mirrors client behaviors of psychosis

Age of 50 years Paraphrenia or late-onset schizophrenia generally occurs later in life and symptoms persist and intensify as the client ages. Schizophrenia is rarely diagnosed after the age of 40 and is considered late-onset if diagnosed after the age of 40.

A nurse is speaking with a client who experienced physical assault. Which of the following actions should the nurse take? Ask the client a series of questions about who assaulted them. Touch the client for reassurance. Insist the client report the incident. Allow the client to control the conversation.

Allow the client to control the conversation. The nurse should allow the client to control the conversation with the nurse. The client should be able to take breaks while talking, decide where to sit in the room, request a glass of water, etc.

A nurse is teaching a client at a prenatal clinic. The client shares that they have family members diagnosed with schizophrenia and wants to know how they can reduce their baby's risk of developing schizophrenia. Which of the following information should the nurse include? Avoid contracting a viral infection. Abstain from getting pregnant as a teenager. Restrict calories to maintain weight. Limit iron intake.

Avoid contracting a viral infection. Viral infections are a complication that can occur during pregnancy that places a child at risk for developing schizophrenia. The client should be instructed to avoid contracting a viral infection.

A nurse is presenting an in-service about the cycle of violence to nursing staff. The nurse should include that which of the following occurs during phase 1 of the cycle of violence? Perpetrator promises to change Perpetrator causes physical harm Law enforcement officers are involved Arguments increase in frequency

Arguments increase in frequency The nurse should include in the teaching that build-up is phase 1 cycle of violence. This is where the breakdown of communication occurs, tensions increase, and/or the victim becomes fearful.

A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take? Tell the client that there is nothing there. Ask the client to describe what is being seen. Remove the client from the room. Touch the client's arm reassuringly.

Ask the client to describe what is being seen. It is the responsibility of the nurse to keep the client as calm and safe as possible, while helping the client to feel understood. By asking what the client sees, the nurse is posing a direct question without arguing about what the client is or is not seeing. This can promote a calm and safe interchange and help the client to feel understood.

A nurse is caring for a client who is experiencing manifestations of opiate withdrawal. When assessing the client, which of the following purposes describes the function of the Clinical Opiate Withdrawal Scale (COWS)? Assess severity of symptoms from withdrawal and treat accordingly. Determine the client's risk of developing severe manifestations. Identify genetic factors that influence opiate withdrawal. Analyze and interpret laboratory and medical imaging data.

Assess severity of symptoms from withdrawal and treat accordingly. The nurse should identify that the COWS provides guidelines for the nurse to follow when rating the severity of the manifestations of opiate withdrawal.

A nurse is caring for a client who has factitious disorder. The client states, "I am so tired of living like this. Maybe I should just end it all." Which of the following actions should the nurse take? Encourage the client to participate in group therapy sessions. Assess the client for suicidal ideation and thoughts of self-harm. Encourage the client to use relaxation techniques. Determine if the client has entered one of their alter personalities.

Assess the client for suicidal ideation and thoughts of self-harm. The nurse should assess the client for a plan and the means to attempt suicide to address the client's safety needs.

A nurse on an inpatient unit is caring for a client who has somatic symptom disorder. The client comes to the nurse's station and reports chest pain. The nurse knows this is a new symptom for the client. Which of the following actions should the nurse take? Explain to the client that the pain is not real. Reassure the client that pain is an expected part of their disorder. Encourage the client to use relaxation techniques. Assess the client's vital signs.

Assess the client's vital signs. The nurse should assess the client's vital signs due to the onset of chest pain, which can indicate a potential medical emergency.

A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place? Implementation Planning Evaluation Assessment

Assessment The assessment phase is the first phase of the nursing process where the nurse interviews the client to collect data.

A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client? Foods that are known to be high in dietary tyramine should be avoided. Increase the dose of medication as needed if relief of manifestations is not experienced. Avoid driving or operating heavy machinery until you know how alprazolam affects you. Relief of manifestations should be expected after a few weeks of therapy.

Avoid driving or operating heavy machinery until you know how alprazolam affects you. The nurse should identify that benzodiazepines can cause sedation; therefore, the nurse should encourage the client to plan their daily activities accordingly, including operating cars or any type of heavy machinery.

A nurse on an inpatient mental health unit is admitting a client. 1400: BP 146/98 mm Hg Heart rate 110/min Respiratory rate 20/min Temperature 37.6° C (99.7° F) SaO2 98% on room air 1400: Client admitted for episode of mania. Diagnosed with bipolar disorder approximately 6 months ago. Parent reports client has been nonadherent to treatment plan for the past several weeks, discontinuing prescribed medication and not attending outpatient therapy. A nurse is reviewing the medical record of a client who recently has been diagnosed with schizophrenia. Which of the following finding is a genetic risk factor associated with the development of schizophrenia? Biologic uncle with Rett syndrome Biologic sibling with Down syndrome. Biologic grandparent with fragile x syndrome Biologic parent with schizophrenia

Biologic parent with schizophrenia A client with a biologic parent who is diagnosed with schizophrenia is six times more likely to develop the disorder.

A nurse is caring for a client who has been newly diagnosed with schizophrenia. Which of the following findings is true regarding this disorder? People diagnosed with schizophrenia are more violent than others. Diagnosis commonly occurs in individuals under the age of 12. Biologically female clients are likely to be diagnosed earlier than biologically born males. Biologically male clients are typically diagnosed earlier than biologically female clients.

Biologically male clients are typically diagnosed earlier than biologically female clients. Biologic males are typically diagnosed with schizophrenia during late adolescence to early twenties.

A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe? Methadone Naloxone Diphenhydramine Benzodiazepines

Benzodiazepines The nurse should identify that benzodiazepines are used to treat alcohol withdrawal.

A nurse is assessing a client who has a history of non-suicidal self-harm (NSSH). Which of the following findings should the nurse identify as manifestations of NSSH? Bruises from hitting oneself Bite marks on the upper arms Erosion of tooth enamel Difficulties managing painful emotions Burn marks on the chest

Bruises from hitting oneself is correct. NSSH is the purposeful injury or damage to one's own body without conscious thoughts of suicide. NSSH is generally performed to help manage difficult emotions. The most common behaviors include cutting, burning, scratching, hitting oneself, or piercing the skin. Bite marks on the upper arms is correct. NSSH is the purposeful injury or damage to one's own body without conscious thoughts of suicide. NSSH is generally performed to help manage difficult emotions. The most common behaviors include cutting, burning, scratching, hitting oneself, or piercing the skin. Difficulties managing painful emotions is correct. NSSH is the purposeful injury or damage to one's own body without conscious thoughts of suicide. NSSH is generally performed to help manage difficult emotions. The most common behaviors include cutting, burning, scratching, hitting oneself, or piercing the skin. Burn marks on the chest is correct. NSSH is the purposeful injury or damage to one's own body without conscious thoughts of suicide. NSSH is generally performed to help manage difficult emotions. The most common behaviors include cutting, burning, scratching, hitting oneself, or piercing the skin.

A nurse is caring for a client who is experiencing periods of hyperactivity, impulsivity, and inattentiveness. Which of the following medications should the nurse anticipate the provider to prescribe? Central nervous system stimulant Dopamine antagonist Benzodiazepine Selective serotonin reuptake inhibitor

Central nervous system stimulant The nurse should identify that central nervous system (CNS) stimulants, such as methylphenidate, are primarily used to treat manifestations of attention deficit hyperactivity disorder (ADHD) and narcolepsy.

A nurse is caring for a client who is experiencing delusions, hallucinations, and alterations in speech. Which of the following medications should the nurse anticipate the provider to prescribe? Dopamine antagonist Mood stabilizer Benzodiazepine Selective serotonin reuptake inhibitor

Dopamine antagonist The nurse should identify that dopamine antagonists, such as antipsychotics, are used to manage manifestations of psychosis, including hallucinations.

A nurse is caring for a client who has illness anxiety disorder. Which of the following medications should the nurse expect the provider to prescribe? Carbamazepine Haloperidol Escitalopram Olanzapine

Escitalopram Escitalopram is a selective serotonin reuptake inhibitor, which can be used to decrease anxiety in clients who have illness anxiety disorder.

A nurse is caring for a client who has a dissociative disorder. Which of the following actions should the nurse take first? Educate the client about their disorder. Administer a benzodiazepine to the client. Establish rapport with the client. Teach the client grounding techniques.

Establish rapport with the client. The first step the nurse should take is to establish rapport with the client during the orientation phase of the therapeutic nurse-client relationship

A nurse is caring for a client who has somatic symptom disorder. The client says to the nurse, "If I can't get the medical help I need, I might as well just end it all." Which of the following actions should the nurse take? Encouraging the client to practice grounding techniques. Instruct the client to verbalize what medical help they think they need. Determine if the client has a suicide plan. Encourage the client to seek care from other providers.

Determine if the client has a suicide plan. The nurse should determine if the client has a plan and the means to attempt suicide in order to address the client's safety needs.

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? Osteoarthritis Diabetes mellitus Cancer Alzheimer's disease

Diabetes mellitus Diabetes mellitus is a comorbidity associated with schizophrenia. This medical condition is typically under-diagnosed and treated in individuals who have schizophrenia, which contributes to early mortality rates among this population. Medical conditions such related to weight gain, diabetes, metabolic syndrome, cardiovascular disease and pulmonary disease are more common in persons with schizophrenia than the general population.

A nurse is caring for a client who ingested a selective serotonin reuptake inhibitor and St. John's Wort. Which of the following findings should the nurse identify as being consistent with serotonin syndrome? Suicidal ideations Dilated pupils and loss of muscle coordination Tinnitus and jerking movements Pill rolling movements and drooling

Dilated pupils and loss of muscle coordination The nurse should identify that dilated pupils and loss of muscle coordination are findings associated with serotonin syndrome.

A nurse is caring for an adolescent client who was sexually assaulted. The client is having difficulty remembering events related to the assault. Which of the following is the client likely experiencing? Dissociative identity disorder Dissociative amnesia Depersonalization/derealization Factitious disorder

Dissociative amnesia With dissociative amnesia, the client would be unable to recall events related to their history in a way that is not consistent with ordinary forgetfulness.

A nurse is conducting an in-service for a group of newly licensed nurses about the interventions used for clients experiencing non-suicidal self-harm (NSSH). Which of the following should the nurse include? Ask the client why they do this as soon as possible. Early recognition is crucial to successful treatment. Recognize non-suicidal self-harm as an attention-seeking behavior. Discourage clients from discussing the NSSH with friends.

Early recognition is crucial to successful treatment. Nurses should use knowledge gained regarding NSSH to improve their understanding and client approach to ensure establishment of a therapeutic nurse-client relationship, thereby increasing positive client outcomes. Interventions include early recognition, available and affordable treatment resources, and educational and supportive services. Open discussion regarding NSSH can help to reduce the occurrence and provide susceptible clients with a venue for help.

A nurse is caring for an older adult client who reports their caregiver has been writing checks in their name without their consent. Which of the following types of abuse is the client experiencing? Emotional Economic Physical Neglect

Economic The nurse should identify the client is experiencing economic abuse. Economic abuse can occur when finances belonging to another person, such as an older adult, are stolen from them. This can include writing checks in the client''s name without their consent and using their personal benefits.

A nurse on a mental health unit is planning care for a client who has a new diagnosis of non-suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan? Encourage the client to identify the emotions they feel immediately before performing the self-harm behavior. Explain to the client that self-harm behaviors do not increase their risk for accidental death. Place the client in one-on-one direct observation due to overt suicidal intent. Inform the client that self-harm behavior cannot become a serious problem in the future.

Encourage the client to identify the emotions they feel immediately before performing the self-harm behavior. Exploring the distress the client is feeling by asking non-judgmental questions can aid the nurse in providing necessary referral services. The nurse should ask questions such as, "what prompted you to do this?", "what happened prior to this?", and "what do you feel when you do this?"

A nurse is caring for a client in an outpatient clinic. Nurses' Notes Week 1:Client reports feelings of anxiety and increased back pain. Client had open heart surgery 1 month ago. "Since I have had the surgery, I feel depressed." Week 2:Client reports fixation on health condition and inability to sleep. Client states, "I don't think the surgery helped. I still am short of breath and don't feel any better. I feel anxious and sick to my stomach. I think there is something wrong with me the doctor hasn't found yet." History and Physical Week 1: Client had open heart surgery 1 month ago. Had multiple cardiac surgeries prior to recent surgery. History of: Coronary artery diseaseHypertensionHyperlipidemiaType 2 diabetes mellitusAnxietySomatic symptom disorderChronic back pain for 10 years Select the 3 interventions the nurse should plan to take. Encourage the client to think positive thoughts. Assist the client in distinguishing between anxiety and physical manifestations. Provide relief measures for manifestations the client is experiencing. Inform the client that nothing is medically wrong with them. Suggest to the client's provider that multiple tests need to be performed. Perform a leng

Encourage the client to think positive thoughts is correct. The nurse should encourage the client to think positive thoughts about their condition. This helps the client think of effective ways to cope with the concerns that are causing them stress. Assist the client in distinguishing between anxiety and physical manifestations is correct. The nurse should assist the client to determine the difference between an anxiety response and a physical manifestation of their condition. Being able to make this distinction can improve the client's coping abilities. Provide relief measures for the manifestations the client is experiencing is correct. The nurse should provide relief measures for the manifestations the client is experiencing. These relief measures can include medication, relaxation techniques, or a change of focus.

A nurse is caring for a client who has schizophrenia. In which of the following phases of the nurse-client relationship should the nurse suggest a guided therapy session? Resolution phase Identification phase Exploitation phase Orientation Phase

Exploitation phase As the nurse builds trust with the client during the plan of care, the working phase, or exploitation phase, is when the nurse seeks to get the client to reveal deep-rooted feelings and concerns. This can frequently be addressed through nonpharmacological interventions such as education or guided therapy sessions.

A nurse is caring for a client who frequently breaks their arms and other bones on purpose. The nurse understands that the client likely has which diagnosis? Illness anxiety disorder Dissociative amnesia Functional neurological symptom disorder Factitious disorder

Factitious disorder Factitious disorder is the conscious falsification of manifestations of an illness or intentionally causing self-injury.

A nurse is reviewing the medical record of a client who reports severe pain in their head and abdomen. The client's blood toxicology test reveals ingestion of a common insect poison. The client states, "I like to feel like I am the center of a TV show medical drama. That is why I took the poison." The client denies suicidal intent or ideation. Which of the following disorders best describes the client's condition? Factitious disorder Functional neurological symptom disorder Illness anxiety disorder Somatic symptom disorder

Factitious disorder This behavior is indicative of factitious disorder, whereby a person consciously pretends to be ill or acts in a way to intentionally cause illness or injury. This disorder was previously known as Munchausen syndrome.

A nurse is providing care to a client who was admitted to the emergency department with superficial lacerations on their leg. The client states, "I was feeling bored, so I used a pair of gardening scissors to cut myself." The client denies current depression and suicidal thoughts. The client is demonstrating manifestations of which of the following disorders? Functional neurological symptom disorder Factitious disorder Illness anxiety disorder Somatic symptom disorder

Factitious disorder Factitious disorder is when a client intentionally falsifies their symptoms in order to garner attention or attain a sick role.

A nurse is assessing a client who has depression and was prescribed fluoxetine 6 months ago. The client reports that they recently stopped taking the prescription. Which of the following findings indicates the client is experiencing antidepressant discontinuation syndrome (ADDS)? Flu-like manifestations Blurry vision Poor coordination Irritability

Flu-like manifestations The nurse should recognize that flu-like manifestations are findings associated with ADDS, which occurs when a client abruptly discontinues antidepressant therapy. Other manifestations of ADDS include difficulty sleeping, anxiety, and depression.

A nurse is caring for a client who states, "When I get in the car to drive to work in the morning, my hands go numb. It is to the point where I can't grip the steering wheel." Which of the following conditions is the client likely experiencing? Factitious disorder Depersonalization/derealization disorder Functional neurological symptom disorder Dissociative amnesia

Functional neurological symptom disorder The client is describing manifestations of temporary paralysis as seen in functional neurological symptom disorder.

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report? Lip smacking and tongue thrusting GI discomfort and poor coordination Blurred vision and jerking motor movements Fever and fluctuating blood pressure

GI discomfort and poor coordination GI discomfort and poor coordination are associated with early lithium toxicity, at a level of 1.5 to 2.0 mEq/L

A nurse is caring for a client in an outpatient clinic. Nurses' Notes Week 1: Client reports feelings of anxiety about a new diagnosis of type 2 diabetes mellitus. Client states, "This can lead to heart disease, having to learn how to self-administer insulin, not to mention that I could even die from this." Week 4: Client visits outpatient clinic once a month and continues to have concerns about the dangers of diabetes mellitus and other concerns of "not feeling well." Month 6: Client seen for feelings of increased anxiety and excessive thoughts of recent diagnosis of type 2 diabetes mellitus. "I can't sleep and now I have pain all over my body all the time. I have diarrhea every day and my stomach hurts when I eat." History and Physical Week 1: Bipolar disorderType 2 diabetes mellitusDepressionHyperlipidemiaFamily history of alcohol use disorder A nurse is assessing a client who has been coming to an outpatient clinic for the last 6 months. The nurse should identify which of the following findings as manifestations of somatic symptom disorder? (Select all that apply.) Anxiety Gastrointestinal distress Pain Bipolar disorder Fixation on health Depression Localized amnesia

Gastrointestinal distress is correct. Clients who have somatic symptom disorder can experience gastrointestinal distress as manifestation. The client needs to experience a manifestation longer than 6 months to meet the DSM-V criteria for this condition. Pain is correct. Clients who have somatic symptom disorder can experience pain as a manifestation. The client who needs to experience a manifestation longer than 6 months to meet the DSM-V criteria for this condition. Fixation on health is correct. Clients who have somatic symptom disorder can experience excessive thinking about their health as a manifestation. This can be related to a new medical diagnosis the client has received, such as type 2 diabetes mellitus. The client will spend excessive time and energy obsessing about their condition or manifestations.

A nurse is caring for a client who has been diagnosed with schizophrenia and is experiencing delusions of being a celebrity. Which of the following delusion types describes this client's behavior? Grandiose Persecutory Control Thought insertion

Grandiose Grandiose delusion is accurate as it is a firmly held belief of a person that they are someone other than who they are - often a person of wealth, fame, or deity

A nurse is providing care to a client is who is recovering from an episode of dissociative amnesia. The nurse should expect the client to exhibit which of the following manifestations? Hallucinations Anhedonia Delusions Guilt

Guilt After experiencing an episode of dissociative amnesia, it is common for an individual to experience symptoms of guilt, rage, dysphoria, shame, and psychological conflict.

A nurse is caring for client who experienced abuse. The client says, "It was my fault. I made my partner upset." The nurse should identify that the client is demonstrating which of the following manifestations? Anger Guilt Dependency Fear

Guilt The nurse should identify that the client is demonstrating guilt, which is a manifestation of a client who has experienced abuse. The client feels the abuse is their fault. Other manifestations can include feelings of powerlessness, fear, dependence, lack of trust, and assertiveness.

A nurse is preparing a presentation about alcohol withdrawal. Which of the following findings should the nurse include in the presentation? Muscle aches Respiratory depression Decreased blood pressure Hallucinations

Hallucinations The nurse should identify that hallucinations are seen in alcohol withdrawal and are caused by hyperexcitation of the central nervous system.

A nurse is caring for a client who describes extreme fear of having or acquiring a disease. The client is also exhibiting behaviors like repeated body checking. The nurse should identify that the client is exhibiting manifestations of which of the following disorders? Somatic symptom disorder Functional neurological symptom disorder Illness anxiety disorder Factitious disorder

Illness anxiety disorder Illness anxiety disorder, previously called hypochondriasis, occurs when a client experiences constant thoughts and worry about having an illness.

The nurse is collecting the health history of a client and determines that the client has risk factors for developing mental illness. Which of the following should the nurse identify as a possible contributing factor in the development of a mental health disorder? Medication adherence Immune system Exposure to environmental allergens Adverse effects of treatment

Immune system The nurse should identify that the relationship between stress and the immune system can be related to the presentation of some manifestations of mental illness.

A nurse is caring for a client who was admitted for alcohol detoxification. Which of the following findings should the nurse expect to observe that indicate the client is experiencing alcohol withdrawal?

Increased heart rate and vomiting The nurse should identify that findings of alcohol withdrawal include manifestations of CNS excitation such as increased heart rate, increased blood pressure, nausea, vomiting, increased risk of seizure, and hallucinations.

A nurse is caring for a client who has a history of being a perpetrator of abuse and violence. Which of following characteristics should the nurse expect the client to have? Communicates in short sentences Intimidates others Shows bravery Is demanding Has low self-esteem Has a low tolerance for frustration

Intimidates others is correct. The nurse should identify intimidating others as a manifestation of a perpetrator of abuse and violence of an abuser/perpetrator. Other manifestations can include a low tolerance for frustration, low self-esteem, intimidating others, being demanding, and blaming others for their problems. Is demanding is correct. The nurse should identify intimidating others as a manifestation of a perpetrator of abuse and violence. Other manifestations can include a low tolerance for frustration, low self-esteem, intimidating others, being demanding, and blaming others for their problems. Has low self-esteem is correct. The nurse should identify intimidating others as a manifestation of a perpetrator of abuse and violence. Other manifestations can include a low tolerance for frustration, low self-esteem, being demanding, and blaming others for their problems. Has a low tolerance for frustration is correct. The nurse should identify intimidating others as a manifestation of a perpetrator of abuse and violence. Other manifestations can include a low tolerance for frustration, low self-esteem, intimidating others, being demanding, and blaming others for their problems.

A nurse is caring for a client who is diagnosed with schizophrenia. Which of the following manifestations should the nurse identify as a negative symptom? Lack of emotions Confusion Paranoia Distorted beliefs

Lack of emotions The nurse should identify lack of emotions as a negative symptom for a client who is diagnosed with schizophrenia. Other negative symptoms can include lack of motivation, lack of interest, lack of energy, withdrawal from others, and absence of speech.

A nurse is reviewing the medical record of a client who has somatic symptom disorder. Which of the following would be a likely comorbidity of somatic symptom disorder? Bipolar disorder Major depressive disorder Borderline personality disorder Schizophrenia

Major depressive disorder Major depressive disorder is the largest comorbidity for somatic symptom disorder.

A nurse is caring for a client who is experiencing manifestations of opiate withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe? Benzodiazepines Naloxone Methadone Diphenhydramine

Methadone The nurse should identify that methadone is an opiate replacement that will help treat clients who are experiencing opiate withdrawal.

A nurse is caring for a school-age client in an outpatient clinic. History and Physica Week 1:Abdominal painAnorexiaChild has had seven hospitalizations in the past 6 months. Nurses' Notes Week 1: Parent brings school-age child to clinic. States, "My child is always sick. Their stomach hurts all the time. Something is wrong with them. This has been going on for the past 3 months. We've been to several doctors, and they can't find anything wrong." Parent reports that child experiences frequent abdominal pain and has a fever. Child appears emaciated and withdrawn with eyes downcast and looking at floor. Skin is pale with decreased turgor. Week 3: Parent brings child back to clinic. Child is vomiting and holding abdomen. Child states, "My stomach hurts so bad." Child looking away from parent. Parent states, "I have taken my child out of school and am home schooling them now. They are too ill to go to school and require my care." Parent is defensive when asked questions related to child's manifestations. Parent is demanding that child be admitted to acute care facility to "have tests run." The nurse should identify which of the client findings are manifestations of a factitious disorder? Se

Multiple hospitalizations is correct. Clients who have factitious disorder can have multiple hospitalizations or even surgeries as a manifestation of this disorder. Unexplained abdominal pain is correct. Clients who have factitious identity disorder can experience unexplained abdominal pain, surgeries, bleeding, fever, hypoglycemia, seizures, or cancer, which can be manifestations that are manufactured or self-inflicted.

A nurse is caring for a client who has sleep dysregulation, poor memory, and poor concentration. Which of the following neurotransmitters should the nurse identify as being responsible for the client's manifestations? Histamine Serotonin Dopamine Norepinephrine

Norepinephrine The nurse should identity that norepinephrine is an excitatory neurotransmitter that is responsible for learning, sleep, mood, memory, and attention.

A nurse is working with clients who were incarcerated and have recently been released from prison. Which of the following pieces of information regarding SMIs should the nurse be aware of? People who have been incarcerated rarely experience inadequate treatment while in prison. term-2 People who have SMIs and have been incarcerated are less likely to be victimized. The majority of people who have been incarcerated at state prisons are treated for a serious mental illness. People who have SMIs and have been incarcerated face a greater risk of discontinuing treatment and relapsing.

People who have SMIs and have been incarcerated face a greater risk of discontinuing treatment and relapsing. People who have SMIs and have been incarcerated often face challenges finding housing and jobs. This puts them at a greater risk of discontinuing treatment after leaving prison and relapsing.

A sexual assault nurse examiner (SANE) is a caring for a client who experienced sexual assault. Which of the following actions should the nurse take? Request the police to gather evidence of the incident. Protect the client from further harm. Require the client to call the police. Provide legal testimony on behalf of the client.

Protect the client from further harm. The SANE should protect the client from further harm by providing the client with options in order to make an informed decision regarding their care.

A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns. Which of the following is the priority nursing intervention for this client? Use distraction such as the television or music. Provide reassurance and comfort ensuring the client is safe. Give PRN medications to treat increased hallucinations. Ensure the client goes to group activities as planned.

Provide reassurance and comfort ensuring the client is safe. This client is exhibiting symptoms of schizophrenia affecting their cognition (ability to think clearly) as well as connection to reality (alterations in speech), resulting in an alteration in executive functioning. The priority is to keep the client safe and create a calm reassuring environment as a first step.

A nurse is caring for a young adult client who has somatic symptom disorder and is being evaluated for chest pain. The client's laboratory results are all within the expected reference ranges, the ECG is unremarkable, and the client has no identified cardiac risk factors. Which of the following actions should the nurse take? Refer the client for flooding therapy. Provide reassurance to the client. Inform the client that the pain is not real. Encourage the client to request invasive cardiac testing.

Provide reassurance to the client. The nurse should provide reassurance while conveying empathy to the client while initially addressing the client's physical concerns. After building a strong therapeutic relationship, the client's caregivers can begin to address the psychosocial concerns.

A nurse is caring for a client who is agitated and threatening to leave against medical advice. The client is pacing the unit and yelling. Which of the following actions should the nurse take? Stand in front of the client when talking. Block the doorway of the unit. Ignore the client's concerns. Set parameters for the client.

Set parameters for the client. The nurse should set parameters for the client as a de-escalation technique for a client who is agitated and threatening to leave against medical advice. This can assist with defusing the situation.

A nurse is caring for a client on a mental health unit. History and Physical Day 1 1400: History of schizophrenia for five years. Multiple hospitalizations for psychosis and depression. Has had electroconvulsive therapy (ECT) in the past. Drinks four to five alcoholic beverages per day. Smokes one pack of cigarettes per day. Reports no drug abuse. No surgeries Hypertension, hyperlipidemia, cirrhosis Nurses' Notes Day 1 1400: Client is restless and states, "I keep hearing voices saying I need to return to my planet. I communicate with them through my television." Client reports hearing voices for the last few weeks. Client's hygiene is poor, clothes are soiled, and has body odor. Client reports difficulty sleeping and hasn't eaten in the last two days. Day 1 1730: Client ate 50% of meal tray. Alert and oriented to person. Able to respond to questions. Reports no pain. Able to ambulate self to bathroom. Day 1 2230: Client is restless, pacing in room, banging head with their hands and states, "Tell the voices to stop!" For each potential medication, click to specify if the potential medication is anticipated, nonessential, or contraindicated for the client. Potential Medication Anticipat

Risperidone is anticipated. Risperidone is a second generation antipsychotic medication used to treat schizophrenia and psychosis. The client is experiencing delusions and hallucinations; therefore, the nurse should anticipate the provider to prescribe this medication for the client. Vallerand 2021 page 1103-1104 National Alliance on Mental Illness, 2020) Halter 2018 page 212,215 Ziprasidone is anticipated. Ziprasidone is a second generation antipsychotic medication used to treat schizophrenia and psychosis. The client is experiencing delusions and hallucinations; therefore, the nurse should anticipate the provider to prescribe this medication for the client. Vallaerand 2021 page 1291 National Alliance on Mental Illness, 2020) Halter 2018 page 212,215 Quetiapine is contraindicated. Quetiapine is a second generation antipsychotic medication used to treat schizophrenia and psychosis; however, the client has cardiovascular disease, which is contraindicated for receiving this medication. Vallerand 2021 page 1075 National Alliance on Mental Illness, 2020) Halter 2018 page 212,215 Haloperidol is contraindicated. Haloperidol is a first generation antipsychotic medication used to treat schizophrenia and psychosis; however, the client has cardiovascular disease and cirrhosis, which are contraindicated for receiving this medication. Vallerand 2021 page 643 National Alliance on Mental Illness, 2020) Halter 2018 page 211

A nurse is caring for a client who is inquiring about the use of herbal remedies in treating manifestations of mental illness. Which of the following topics should the nurse prepare to discuss with the client? Most herbal remedies do not interact with prescription medications. Discourage the use of herbal remedies in treating manifestations of mental illness. Herbal remedies are not effective in treating manifestations of mental illness. Serotonin syndrome can occur when using herbal remedies.

Serotonin syndrome can occur when using herbal remedies. The nurse should identify that herbal remedies can interact with prescribed medications, such as fluoxetine. This combination could potentially lead to the development of serotonin syndrome.

A nurse is caring for a client who has substance use disorder and is experiencing acute toxicity to sedatives, but has no history of schizophrenia spectrum disorders. Which of the following manifestations should the nurse expect the client to experience? Negative symptoms of psychosis Prolonged hallucinations Severe hallucinations Prolonged delusions

Severe hallucinations Brief severe psychotic symptoms such as hallucinations and delusions can occur with substance use disorder, such as acute toxicity to a sedative.

A nurse is providing information regarding the social determinants of mental health and persons with serious mental illnesses (SMI). Which of the following pieces of information should the nurse share during the presentation? Social determinants can be an advantage or a challenge to treatment for an SMI. The client will be unable to change any of their social determinants of health. Treatment is usually enough to overcome any social determinants. Social determinants of health are mostly negative effects on a person's physical health.

Social determinants can be an advantage or a challenge to treatment for an SMI. Treating a serious mental illness can be helped or hindered by the client's social determinants of health, such as their housing, social support, and other factors. It can help clients to be aware of the factors that can influence their treatment.

A nurse is planning discharge for a client who has schizophrenia and reports "I don't have a place to live." Which of the following referrals should the nurse request from the provider? Psychiatrist Employment assistance Spiritual advisor Social worker

Social worker A social worker is a professional who can coordinate specialty care and community assistance for clients who have a mental health disorder diagnosis and have social issues such as homelessness.

FLAG A community health nurse is presenting epidemiological and etiological data related to somatic symptom disorder and related disorders. Which of the following information should the nurse include? Clients who have this disorder are intentionally faking their symptoms. Clients who have somatic symptom disorder exhibit more than one personality. Somatic symptom disorder impacts more women than men. Somatic symptom disorder impacts the majority of clients who have depression.

Somatic symptom disorder impacts more women than men. Women tend to report more somatic symptoms than men, thus the prevalence of somatic symptom disorder is higher in women.

A nurse is working with an older adult client who has been diagnosed with somatic symptom disorder. Which of the following should the nurse consider when working with an older adult who has somatic symptom disorder? Somatic symptom disorder is usually underdiagnosed in the older population. Somatic symptom disorder must be diagnosed before 18 years of age. Somatic symptom disorder is usually onset in older adulthood. Somatic symptom disorder is usually diagnosed in early childhood.

Somatic symptom disorder is usually underdiagnosed in the older population. Manifestations of somatic symptom disorder are usually masked by normal signs of aging in the older adult population.

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor? Severe restlessness Respiratory depression and a comatose state Sore throat and muscle aches Increased anxiety and suicidal ideations

Sore throat and muscle aches The nurse should identify that flu-like manifestations, such as a sore throat and muscle aches, are findings associated with agranulocytosis, a potentially life-threatening adverse effect.

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor? Respiratory depression and a comatose state Increased anxiety and suicidal ideations Sore throat and muscle aches Severe restlessness

Sore throat and muscle aches The nurse should identify that flu-like manifestations, such as a sore throat and muscle aches, are findings associated with agranulocytosis, a potentially life-threatening adverse effect.

A nurse is providing care for a client who experienced sexual assault. Which of the following communication strategies should the nurse use? Speak softly to the client. Provide direct eye contact with the client. Ask open-ended questions about the perpetrator. Sit next to the client.

Speak softly to the client. The nurse should speak softly as a communication strategy when addressing a client who experienced sexual assault. This provides a calm and therapeutic environment for the client.

A nurse is asking a client who has schizophrenia about their cultural and spiritual beliefs. Which of the following is the purpose for collecting this information? To decrease the client's stress To empower the client to be engaged in personal care To detect changes in the client's condition To increase the client's motivation to learn about their culture

To empower the client to be engaged in personal care The nurse should address cultural and spiritual beliefs to provide culturally sensitive care that is tailored to the client's needs. Asking questions about cultural and spiritual beliefs keeps the client actively engaged in the care plan.

A nurse is speaking about types of aggression to a group of residents at a community outreach center. One of the attendees states, "I keep seeing the same person outside my apartment and they are leaving me items at my door." Which of the following types of aggression should the nurse identify the client is experiencing? Assault Bullying Stalking Abandonment

Stalking The nurse should identify that the client is experiencing stalking or unwanted attention from another person. This can include following or watching someone, monitoring where someone lives, leaving items and obtaining personal information about them. A stalker can show up at the person's home or place of work unannounced. A stalker can also contact the person multiple times via phone calls, emails, letters, or text messages.

A nurse is caring for a client who has mental illness. The client heard their employer say they think the client will become violent because they have a mental illness. Which of the following social beliefs is the client experiencing? Nonadherence Victimization Anosognosia Stigma

Stigma The nurse should identify t

A nurse is caring for a client who has psychosis and is prescribed chlorpromazine. The client reports feelings of restlessness. The nurse should identify that the client should be monitored for which of the following adverse effects? Shuffling walk Abnormal movements of the tongue and face Suicidal ideation Oculogyric crisis

Suicidal ideation The nurse should identify that chlorpromazine is a first-generation antipsychotic (FGA) that can cause akathisia, or feelings of restlessness not relieved by movement. Clients can develop suicidal ideation when experiencing akathisia.

A nurse is speaking to a group of nurses about the difference between schizoaffective disorder and schizophrenia. Which of the following findings is associated with the active phase of schizoaffective disorder? Symptoms of major depression or mania Absence of delusions or hallucinations Anosognosia is more severe More severe negative symptoms

Symptoms of major depression or mania A nurse should expect symptoms of major depression or mania to occur during the active phase of schizoaffective disorder.

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. Which of the following is the client experiencing? Impaired ability to regulate body temperature Neuroleptic malignant syndrome Tardive dyskinesia Extrapyramidal symptoms

Tardive dyskinesia Tardive dyskinesia is an adverse effect of antipsychotic medication that causes jerking movements and twitching of the face and tongue.

A charge nurse in a mental health facility is teaching a newly licensed nurse how to perform an Abnormal Involuntary Movement Scale (AIMS) assessment on a client. The charge nurse should identify that the AIMS assessment is used for which of the following conditions? Lithium toxicity Tardive dyskinesia Opiate withdrawal Alcohol withdrawal

Tardive dyskinesia The nurse should identify that the AIMS assessment is commonly used by mental health professionals to determine the level of severity and types of abnormal movements present in tardive dyskinesia.

A nurse is caring for a client who has somatic symptom disorder. Which of the following actions should the nurse take? Ensure the client is prescribed pain medication. Teach the client how to use relaxation techniques. Encourage the client to increase their intake of carbohydrates. Schedule the client to meet with their primary care provider weekly

Teach the client how to use relaxation techniques. Effectively managing stress can help decrease the symptoms of somatic symptom disorder.

A nurse is educating a client about mental illness and the client asks, "Why do some people who take medications experience resolution of clinical manifestations of their mental illness while other people experience relapses or worsening clinical manifestations?" Which of the following statements should the nurse make? "It's uncommon to experience manifestations after a few days of medication treatment." "Adhering to a medication regimen will likely cure mental illness." "The willpower of the client determines manifestations remission." "The brain's ability to adapt is very individual and plays a role in symptom severity."

The brain's ability to adapt is very individual and plays a role in symptom severity." The nurse should identity that neuroplasticity, or the brains synaptic connections, explains why in some mental illnesses, such as major depressive disorder, some individuals experience an increase in severity of clinical manifestations over time and may require a different course of treatment.

A nurse is sharing information with a client who has been diagnosed with a serious mental illness (SMI) and their family about living with an SMI. Which of the following information should the nurse include? The client might experience periods of remission from the manifestations of their SMI. Most clients find their SMI becomes easier to manage as they get older. The client's treatment will focus on helping the client manage their manifestations. With treatment, the client is unlikely to relapse after their initial diagnosis.

The client might experience periods of remission from the manifestations of their SMI. Clients might experience periods of remission or times when symptoms of their SMI are less severe. Treatment can help clients achieve a better quality of life.

A home health nurse has been caring for a client for the past 3 months. Which of the following findings suggest the client is experiencing potential exploitation? The client states that their bank account has unexplained withdrawals of money. The client states that their rings and necklaces are missing. They client states they received a disconnection notice for the light bill after a family member stated they would pay it. The client states that the money in their safety deposit box has decreased over the past few months. The client states they are suddenly unable to log into their online bank account. The client states that the mortgage payment is set on an automatic bank draft.

The client states that their bank account has unexplained withdrawals of money is correct. The nurse should recognize that economic abuse, or exploitation, is the misuse of another person's financial resources. Signs of exploitation include sudden changes in bank accounts or banking practices, unexplained withdrawals, bills that are unpaid despite money being available to pay them, unauthorized signatures on bank cards, sudden transfer of assets, sudden changes in a will or financial documents, unexplained disappearance of funds or possessions, an individual's lack of memory in signing financial documents, or an individual's report of exploitation. The client states that their rings and necklaces are missing is correct. The nurse should recognize that economic abuse, or exploitation, is the misuse of another person's financial resources. Signs of exploitation include sudden changes in bank accounts or banking practices, unexplained withdrawals, bills that are unpaid despite money being available to pay them, unauthorized signatures on bank cards, sudden transfer of assets, sudden changes in a will or financial documents, unexplained disappearance of funds or possessions, an individual's lack of memory in signing financial documents, or an individual's report of exploitation. The client states they received a disconnection notice for the light bill after a family members stated they would pay it is correct. The nurse should recognize that economic abuse, or exploitation, is the misuse of another person's financial resources. Signs of exploitation include sudden changes in bank accounts or banking practices, unexplained withdrawals, bills that are unpaid despite money being available to pay them, unauthorized signatures on bank cards, sudden transfer of assets, sudden changes in a will or financial documents, unexplained disappearance of funds or possessions, an individual's lack of memory in signing financial documents, or an individual's report of exploitation. The client states that the money in their safety deposit box has decreased over the past few months is correct. The nurse should recognize that economic abuse, or exploitation, is the misuse of another person's financial resources. Signs of exploitatio

A nurse in an emergency department is caring for a client who reports having experienced sexual abuse. The nurse should identify that which of the following findings are consistent with the client's report? The client's underwear is bloody. The client has anal bleeding. The client has bruising around the breasts. The client has a scar on their inner thigh. The client's urine sample is positive for chlamydia. The client complains of pelvic soreness.

The client's underwear is bloody is correct. The nurse should recognize that sexual abuse is any forced, inappropriate, or unwanted sexual contact. Signs of sexual abuse include sexually explicit photographs, indecent exposure, unwanted touching, rape, sudden changes in behavior, sexually explicit behavior, sudden bedwetting, inappropriate interest in human sexuality, discomfort or bruises around the breasts or genital area, unexplained sexually transmitted infections (STI's), unexplained vaginal or anal bleeding, torn, stained, or bloody underclothes, or an individual report of sexual abuse. The client has anal bleeding is correct. The nurse should recognize that sexual abuse is any forced, inappropriate, or unwanted sexual contact. Signs of sexual abuse include sexually explicit photographs, indecent exposure, unwanted touching, rape, sudden changes in behavior, sexually explicit behavior, sudden bedwetting, inappropriate interest in human sexuality, discomfort or bruises around the breasts or genital area, unexplained sexually transmitted infections (STI's), unexplained vaginal or anal bleeding, torn, stained, or bloody underclothes, or an individual report of sexual abuse. The client has bruising around the breasts is correct. The nurse should recognize that sexual abuse is any forced, inappropriate, or unwanted sexual contact. Signs of sexual abuse include sexually explicit photographs, indecent exposure, unwanted touching, rape, sudden changes in behavior, sexually explicit behavior, sudden bedwetting, inappropriate interest in human sexuality, discomfort or bruises around the breasts or genital area, unexplained sexually transmitted infections (STI's), unexplained vaginal or anal bleeding, torn, stained, or bloody underclothes, or an individual report of sexual abuse. The client's urine sample is positive for chlamydia is correct. The nurse should recognize that sexual abuse is any forced, inappropriate, or unwanted sexual contact. Signs of sexual abuse include sexually explicit photographs, indecent exposure, unwanted touching, rape, sudden changes in behavior, sexually explicit behavior, sudden bedwetting, inappropriate interest in human sexuality, discomfort or bruises around the breasts or geni

A nurse is caring for a client who has been prescribed clozapine. Which of the following topics should the nurse prepare to discuss with the client? The importance of limiting fluid intake when taking an antipsychotic The importance of medication adherence after the resolution of acute psychosis when taking an antipsychotic The importance of routine red blood cell count laboratory work when taking an antipsychotic The importance of avoiding foods that contain tyramine when taking an antipsychotic

The importance of medication adherence after the resolution of acute psychosis when taking an antipsychotic The nurse should identify that some clients might be tempted to stop taking their medications after manifestations of psychosis resolve, but it is necessary to adhere to the medication regimen.

A newly licensed nurse asks the charge nurse about functional neurological symptom disorder. Which of the following responses should the charge nurse make? Clients who have this disorder consciously control the manifestations." "The manifestations of this disorder are worse during times of increased stress." "Clients who have this disorder exhibit more than one personality.""Feeling outside of one's body is a primary manifestation of this disorder."

The manifestations of this disorder are worse during times of increased stress." The manifestations of neurological symptom disorder often worsen or become more apparent when a client is experiencing a stressful situation.

A nurse is teaching a client who has been newly diagnosed with schizophrenia. Which of the following information should the nurse include? The need for resources increases as the disease progresses into adulthood. Co-occurring mental health illnesses are rarely diagnosed. Diagnosis typically occurs after 40 years of age. Life expectancy is 50.2 years of age in the U.S.

The need for resources increases as the disease progresses into adulthood. As the disorder progresses, 90% of individuals who have schizophrenia continue to experience symptoms requiring additional financial need and resources. This information should be included in the teaching.

A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? Hallucinations Inability to initiate activities Disorganized behavior Lack of emotional expression Antisocial personality Impaired interpersonal relationships

The nurse should identify that hallucinations is one of the symptoms that will assist with the diagnosis of schizophrenia. Of the diagnostic criteria for schizophrenia, the client must experience at least one of the following symptoms: hallucinations, delusions, disorganized behaviors, disorganized speech, or negative symptoms of psychosis. The inability to initiate activities is a negative symptom of schizophrenia. Although negative symptoms are considered part of the diagnostic criteria for schizophrenia, a client must experience at least one of the following symptoms for diagnosis to occur: hallucinations, delusions, disorganized behaviors, disorganized speech or negative symptoms of psychosis. Disorganized behavior is a manifestation that is part of the diagnostic criteria for schizophrenia. According to the DSM-5 criteria, a client must experience at least one of the following hallucinations, delusions, disorganized behaviors, disorganized speech, or negative symptoms of psychosis for diagnosis to occur. The lack of emotional expression is a negative symptom of schizophrenia. Negative symptoms are considered part of the diagnostic criteria for schizophrenia, a client must experience at least one of the following symptoms for diagnosis to occur: hallucinations, delusions, disorganized behaviors, disorganized speech, or negative symptoms of psychosis. . Impaired interpersonal relationships is an example of a person's ability to function. Of the diagnostic criteria for schizophrenia, the client must experience at least one of the following symptoms: hallucinations, delusions, disorganized speech, disorganized behaviors or negative symptoms of psychosis.

A nurse on an inpatient mental health unit is admitting a client. Nurses' Notes 1400: Admission completed, client oriented to unit and room. Discussed unit schedule and routines. Client required verbal refocusing throughout conversation, easily distracted. 1530: Client pacing rapidly through hallways. Fists are clenched. Client yelled at another client in hallway to "get out of my way or else!" Calmly reminded client of unit rules for behavior and consequences of unacceptable behavior. Walked client back to their room. History and Physica 1400: Client admitted for episode of mania. Diagnosed with bipolar disorder approximately 6 months ago. Parent reports client has been nonadherent to treatment plan for the past several weeks, discontinuing prescribed medication and not attending outpatient therapy. vital Signs 1400: BP 146/98 mm Hg Heart rate 110/min Respiratory rate 20/min Temperature 37.6° C (99.7° F) SaO2 98% on room air The nurse is continuing to care for the client. Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. 1400: BP 146/98 mm Hg Heart rate 110/min Respiratory rate 20/min Temperature 37.6° C (99.7°

The nurse should recognize the cues that the client's blood pressure and heart rate are above the expected reference ranges, while the client's pacing, clenched fists, and yelling at other clients indicate anxiety and an increased risk for violence. Therefore, these findings require immediate follow-up. The nurse should recognize the cues that the client's respiratory rate, temperature, and oxygen saturation are within the expected reference ranges and do not require immediate follow-up.

1400: Admission completed, client oriented to unit and room. Discussed unit schedule and routines. Client required verbal refocusing throughout conversation, easily distracted. 1530: Client pacing rapidly through hallways. Fists are clenched. Client yelled at another client in hallway to "get out of my way or else!" Calmly reminded client of unit rules for behavior and consequences of unacceptable behavior. Walked client back to their room. The nurse is continuing to care for the client. Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. 1400: BP 146/98 mm Hg Heart rate 110/min Respiratory rate 20/min Temperature 37.6° C (99.7° F) SaO2 98% on room air 1530: Client pacing rapidly through hallways. Fists are clenched. Client yelled at another client in hallway to "get out of my way or else!" Calmly reminded client of unit rules for behavior and consequences of unacceptable behavior. Walked client back to their room.

The nurse should recognize the cues that the client's blood pressure and heart rate are above the expected reference ranges, while the client's pacing, clenched fists, and yelling at other clients indicate anxiety and an increased risk for violence. Therefore, these findings require immediate follow-up. The nurse should recognize the cues that the client's respiratory rate, temperature, and oxygen saturation are within the expected reference ranges and do not require immediate follow-up.

A nurse is caring for a client who was recently re-admitted for relapse of psychosis symptoms due to not taking their medications. Which of the follow should be a long-term goal for this client? To develop and acknowledge understanding of a relapse plan prior to discharge To be reoriented to their current environment as needed To keep the client's environment calm and with minimal daily stimuli To ensure the client participates in a walk with staff on a daily basis

To develop and acknowledge understanding of a relapse plan prior to discharge A relapse plan is a vital goal for clients who have schizophrenia spectrum disorders. It provides recognition of symptoms and what to do if relapse occurs. This is an important aspect of client recovery.

A nurse is providing care for a client who has schizophrenia. The client is unemployed and unhoused. Which of the following concepts regarding themselves should the nurse be aware of? Unconscious bias Social determinants of health Treatment protocols Health equity

Unconscious bias Unconscious bias is an internal look by the nurse into their own thoughts and beliefs about individuals and groups, which is often called stereotyping. These can interfere with the client's right to receive equitable care. It is the responsibility of the nurse to engage in self-reflection, continuing education courses to promote open discussion about personal biases, and to determine ways of resolving any deep-rooted beliefs that might impede the ability to provide equitable care.

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client? Hallucinations and delusions Seizures and tremors Nausea and vomiting Uncontrolled movements around the mouth

Uncontrolled movements around the mouth Tardive dyskinesia can cause uncontrolled movements around the mouth. It can occur because of long-term anti-psychotic medication use.

A nurse is caring for a client who is taking fluphenazine and is experiencing tardive dyskinesia. Which of the following medications should the nurse anticipate the provider to prescribe for this client? Diphenhydramine Fluoxetine Valbenazine Naloxone

Valbenazine The nurse should anticipate the provider to prescribe valbenazine to treat the manifestations of tardive dyskinesia.

A nurse is caring for a client who was recently diagnosed with somatic symptom disorder. The client says to the nurse, "I don't understand, they can't find anything medically wrong with me. I guess I will never feel better." Which of the following responses is the most therapeutic? "Why do you feel like you will never get better? Do you not have confidence in the medical team?" "Although there isn't a cure for this disorder, I am sure you will feel better someday." "Let's focus on the physical symptoms that you have." "We will work with you to help you develop ways to manage your symptoms that are caused by the disorder."

We will work with you to help you develop ways to manage your symptoms that are caused by the disorder." The primary goal of treatment is symptom management. With proper treatment, reduction in symptoms is possible.

A nurse is caring for a client who has schizophrenia. Nurses' Notes Day 1 1230: A 38-year-old client who has schizophrenia is admitted. Diagnosed 15 years ago. Client reports, "I have been hearing voices again telling me to hurt myself. I hear voices at nighttime so I am not sleeping well." Day 1 1730: Client consumed 35% of evening meal. Client appears nervous but reports not hearing voices at this time. Day 1 1930: Nurse enters client's room. Client is standing on bed and states, "Do you see that man? He is telling me he is going to hurt me." Client pointing to corner of room. Client is talking to themselves and states, "I don't want to hurt myself. Tell the voices to go away!" Nurse asks client who they are talking to and states, "Tell me more about who is trying to hurt you." Vital Signs Day 1 1530: Temperature 37° C (98.6° F) Heart rate 92/min Respiratory rate 20/min Blood pressure 132/68 mm Hg Oxygen saturation: 98% on room air Day 1 1930: Temperature 37° C (98.6° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 156/92 mm Hg Oxygen saturation: 98% on room air The nurse is reviewing the client's medical record. Select the "3" findings that require immediate follow-up by

When analyzing cues, the nurse should identify that the client's blood pressure, hallucinations, and delusions require immediate follow-up by the nurse. The client's blood pressure is outside the expected reference range, indicating hypertension, which can be related to the client's level of paranoia due to hallucinations and delusions they are experiencing; therefore, this finding requires immediate follow-up by the nurse. The nurse should identify the client is experiencing hallucinations by seeing someone in their room and hearing voices who are not there; therefore, this finding requires immediate follow-up by the nurse. The nurse should identify the client is experiencing delusions by hearing voices and stating someone is trying to hurt them who is not there; therefore, this finding requires immediate follow-up by the nurse.

A nurse is caring for a client who has schizophrenia. Day 1 1030: A 35-year-old client who has schizophrenia is admitted. Diagnosed 15 years ago. Brought in by partner and states client has remained in room for the last several days and movements are delayed. Day 1 1730: Client refuses to eat or drink. Client appears withdrawn and does not engage in conversation. Client has flat affect. Does not want to go to therapy session and wants to sleep. Client's movements are slow. Vital Signs Day 1 1030: Temperature 37° C (98.6° F) Heart rate 72/min Respiratory rate 20/min Blood pressure 132/38 mm Hg Oxygen saturation: 99% on room air Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia. Blood pressure Lack of motivation Change in behavior Lack of energy Withdrawn

When analyzing cues, the nurse should identify that the client's lack of motivation, lack of energy, and withdrawn behavior are negative symptoms of schizophrenia. The nurse should identify the client experiencing lack of motivation as evidenced not wanting to attend therapy session or eat/drink are negative symptoms related to the client's schizophrenia. The nurse should identify the client's lack of energy as evidenced by wanting to not sleep is a negative symptom related to the client's schizophrenia. The nurse should identify the client's lack of motivation or being withdrawn is a negative symptom related to the client's schizophrenia.

A nurse on a mental health unit is caring for a client. History and Physical Borderline personality disorder, diagnosed 2 years ago. History of non-suicidal self-injury, intermittently cutting forearms for past 3 years. History of a suicide attempt 2 days ago via prescribed medications. Client medically stabilized on medical/surgical unit then transferred to mental health unit. Nurse's Notes 1300: Client openly participated in group therapy and provided validating feedback to peers. Described a longstanding pattern of frequent changes in their life: changes in hobbies, employment, and in their friends. Reports a history of giving their best friends numerous gifts and constantly calling them every day, only to suddenly ignore and belittle them, followed by regret for doing so. Client also shared that they frequently feel "super nervous" and are restless for no known reason. Client reports that this anxiety makes sleeping and focusing on tasks difficult. 1530: The client approached the nurse's station and attempted to interrupt a staff member who was talking on the phone. After noticing the staff member has a hearing impairment, the client loudly yelled, "Are you deaf or something?" and wa

When generating solutions while planning care for this client, the nurse should determine if the client is having thoughts of harming themselves or others. Clients who have borderline personality disorder often exhibit self-injurious behaviors, such as cutting or scratching. They also often experience suicidal ideation, even chronically, and have a higher risk for death by suicide. Feelings of hostility and anger are also common with this disorder, increasing the risk for violence toward others. The nurse should encourage the client to verbalize their feelings to diffuse frustration and other emotions. Clients who have borderline personality disorder experience emotional lability; therefore, verbalization of these emotions can decrease the impulsive behaviors often exhibited by clients who have this disorder. The nurse should establish consequences for unacceptable behavior such as manipulation and impulsivity, which are manifestations of this disorder. Clearly communicate expected behaviors and the subsequent consequences when unacceptable behavior occurs. The nurse should also provide clear boundaries for behaviors toward peers as clients who have this disorder can exhibit aggression and manipulation of others for their own benefit. The nurse should instruct the client on coping mechanisms and relaxation techniques. Clients who have borderline personality disorder also often have another mental illness, such as depression or anxiety disorder. The client verbalized feeling anxious and restless and that these feelings are disrupting their sleep and ability to focus. Therefore, identifying and practicing coping mechanisms and relaxation techniques are interventions that can decrease the client's anxiety.

A nurse on a mental health unit is caring for a client. History and Physical History of childhood emotional and physical neglect by parents. Mother has schizophrenia. Client diagnosed with paranoid personality disorder last year but has not followed outpatient treatment plan. Reports smoking 8 to 10 cigarettes a day and drinking vodka when available. Currently unemployed; was terminated from job after having altercations with other employees due to paranoid thoughts. Provider Prescriptions Pimozide 1 mg PO once daily Diazepam 5 mg PO every 6 hr PRN anxiety, agitation Nurses' Notes 0815: ED note: Client brought to emergency department (ED) by law enforcement after they responded to a call at a local grocery store. Per the police officer's report, the client was carrying a baseball bat and yelling at customers in the parking lot. When the officer approached the client, the client charged the officer and pushed them down. Client currently in handcuffs sitting in chair in exam room. Clothes dirty, client noted to be frequently scanning the room with their eyes. 0900: ED note: Handcuffs removed by police officer. Accompanied client to bathroom to void. Client now sitting on gurney in exam r

When taking action for a client who has paranoid personality disorder, the nurse should place the client in a room near the nurse's station for close monitoring due to the client's increased risk for violence. The nurse should administer diazepam, a benzodiazepine, to reduce agitation and anxiety, which decreases the risk for aggression and violent behaviors. The nurse should also determine if the client is experiencing command hallucinations as this can be an emergent situation if the client hears voices telling them to harm themselves or others. The nurse should establish clear limits for the client's behavior, as well as consequences for unacceptable behavior.

A nurse on a mental health unit is caring for a newly admitted client. 2100: BP 122/78 mm Hg Heart rate 90/min Respiratory rate 18/min Temperature 36.8° C (98.3° F) SaO2 97% on room air 2345: BP 138/84 mm Hg Heart rate 104/min Respiratory rate 22/min SaO2 98% on room air 2100: Admission completed and client oriented to room. Client immediately fell asleep on bed. 2300: Client awake. Glass of water provided. Denies pain or needs at this time. Encouraged to rest. 2345: Client remains awake and is pacing in room. Noted to have clenched jaw and appears anxious. The nurse is continuing to care for the client. Which of the following actions should the nurse take? Assist the client to identify the source of anger. Employ active listening skills when communicating with the client. Explain the expected behavioral limits to the client. Administer an anxiolytic medication to the client. Gently place a hand on the client's arm during conversation.

When taking action, the nurse should assist the client with identifying their source of anger. The nurse should assist the client in identifying the thoughts or feelings leading up to the anger in order to assist in de-escalation and decrease their risk for violence. The nurse should also employ active listening skills when communicating with the client, along with explaining expected behavior limits to the client. The use of therapeutic communication techniques, such as active listening, build rapport and show respect for the client, which can decrease their anger and their risk for violence. Setting clear, concise limits for acceptable behaviors can assist the client in maintaining control, which can decrease the risk for violence. If needed, the nurse should administer an anxiolytic medication, which can decrease anxiety and feelings of anger, thus decreasing their risk for violence. intervention when taking action for the client. The nurse should allow for additional personal space when talking with a client who has a history of violence or is exhibiting manifestations of anger. The nurse should not touch the client as this can be interpreted as aggression toward the client, increasing their risk for violence.

A nurse is caring for a client who has schizophrenia. Which of the following findings indicates that the client is in the prodromal phase? Frequent hallucinations Incoherent speech Withdrawn behavior Severe delusions

Withdrawn behavior Uncharacteristically withdrawn behavior is a symptom of the prodromal phase, which is the initial phase of the disorder and is marked by less severe symptoms of delusions and hallucinations.

A nurse is providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed? Older adulthood Preschooler School-age Young adulthood

Young adulthood Schizophrenia is typically diagnosed at 16 to 30 years of age, or late adolescence to young adulthood. This information should be included when teaching a group of staff members about the age a client is typically diagnosed with schizophrenia.