Exam 2 - Mental Health Questions

Which term or phrase would the nurse chart about the thought processes to describe a client with schizophrenia who says "Yes, it is March. March is Little Woman. That is literal, you know?". A: Echolalia B: Neologisms C: Flight of Ideas D: Loose association

D: Loose association

The nurse is creating a plan of care for a newly admitted client at high risk for suicide. With the focus of the plan being to promote a safe and therapeutic environment, which intervention should the nurse include? 1. Place the client in a private room. 2. Establish a therapeutic relationship. 3. Assign a leadership task to the client. 4. Maintain a distance of 10 inches at all times.

2. Establish a therapeutic relationship.

A client diagnosed with bipolar disorder is prescribed lithium carbonate. The nurse who administers the medication knows that lithium is used primarily to treat which condition? 1. Suicidal ideations 2. The manic phase of bipolar disease 3. Both depressive and manic episodes 4. The depressive phase of bipolar disease

2. The manic phase of bipolar disease

A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1.Figs 2.Yogurt 3.Crackers 4.Aged cheese 5.Tossed salad 6.Oatmeal raisin cookies

3. Crackers 5. Tossed Salad With MAOIs, the client should avoid ingesting foods that are high in tyramine. Ingestion of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; and fruits such as avocados, raisins, or figs.

The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? A: Parkinsonism B: Tardive dyskinesia C: Hypertensive crisis D: Neuroleptic malignant syndrome

B: Tardive dyskinesia

A client says, "Sky, flower, angry, green, opposite, blanket." Which term describes this type of communication? A. Echolalia B. Word salad C. Confabulation D. Flight of ideas

B: Word Salad

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? A: Incessant talking and sexual innuendoes B: Grandiose delusions and poor concentration C: Outlandish behaviors and inappropriate dress D: Nonstop physical activity and poor nutritional intake

D: Nonstop physical activity and poor nutritional intake Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1. Provide authority, action, and participation. 2. Display an attitude of detachment, confrontation, and efficiency. 3. Demonstrate confidence in the client's ability to deal with stressors. 4. Provide hope and reassurance that the problems will resolve themselves.

1. Provide authority, action, and participation.

The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the pre-procedural plan? Select all that apply. 1.Have the client void. 2.Obtain an informed consent. 3.Administer tap water enemas. 4.Avoid discussing the procedure. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours.

1.Have the client void. 2.Obtain an informed consent. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours.

A depressed client is found unconscious on the floor in the dayroom of a health care facility. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse? 1. Call the poison control center. 2. Call the emergency response team. 3. Determine the exact number of pills taken. 4. Induce vomiting and notify the primary health care provider.

2. Call the emergency response team.

The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT) to treat depression. Which medical diagnosis, if noted on the client's record, would indicate a need to contact the psychiatrist scheduled to perform the ECT? 1. Type 2 diabetes mellitus 2. Peripheral vascular disease 3. Recent myocardial infarction 4. Newly diagnosed hyperthyroidism

3. Recent myocardial infarction Several conditions present risks in the client scheduled for ECT. These include recent myocardial infarction, stroke (brain attack), and cerebrovascular malformation or an intracranial lesion. The conditions in the remaining options do not present specific risks associated with ECT.

In formulating a discharge teaching plan, the nurse should include which precaution for a client with bipolar disorder who is prescribed lithium carbonate therapy? 1. Avoid soy sauce, wine, and aged cheese. 2. Have the blood lithium level checked every 2 weeks. 3. Take the medication only as prescribed to avoid becoming addicted. 4. Check with the psychiatrist before using any over-the-counter medications.

4. Check with the psychiatrist before using any over-the-counter medications.

When planning discharge care for a client diagnosed with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement? 1."I hope I am going to like my new counselor." 2."I sure hope I will still be productive at work." 3."I am going to keep a close check on any stress I have in my life." 4."I will take the medicine until I am sure I can handle my own problems."

4."I will take the medicine until I am sure I can handle my own problems."

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level? A: Toxic B: Normal C: Slightly above normal D: Excessively below normal

A: Toxic

Which term would the nurse use to describe a female client who states that she no longer enjoys any of the activities that she once found fun and pleasureable? A: Anergia B: Anhedonia C: Grandiosity D: Tangentiality

B: Anhedonia

A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. Which is the immediate nursing action? 1. Take the client's vital signs, including pulse oximetry reading. 2. Assess the client's respiratory status and for the presence of neck injuries. 3. Perform a focused assessment, paying particular attention to the client's neurological status. 4. Call the mental health crisis team and notify them that a client who attempted suicide is being admitted.

2. Assess the client's respiratory status and for the presence of neck injuries.

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize which assessment finding as requiring immediate intervention? 1. Grandiose delusions of being a czar of Russia 2. Constant physical activity and poor oral intake 3. Constant, incessant talking, with sexual innuendoes 4. Outlandish behaviors and wearing odd, eccentric clothing

2. Constant physical activity and poor oral intake

The spouse of a client prescribed an antidepressant tells the home health nurse, "Now that the antidepressant is working, the suicidal risk is over and you can stop making these home visits." How does the nurse appropriately respond? 1. "I need to continue with my visits since this disease tends to run in families." 2. "I agree with you that the medication will greatly reduce the risk for suicidal behavior." 3. "I agree with you that continuing to visit would reintroduce the possibility of suicidal ideations." 4. "I need to continue visiting since the client may now have the energy to act on suicidal intentions."

4. "I need to continue visiting since the client may now have the energy to act on suicidal intentions."

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

4. "You sound very upset. Are you thinking of hurting yourself?"

Which type of hallucination is the most common? A: Visual B: Tactile C: Auditory D: Olfactory

C: Auditory

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention should the nurse include in the plan? A: Suggesting a reduction of medication B: Allowing increased "in-room" activities C: Increasing the level of suicide precautions D: Allowing the client off-unit privileges as needed

C: Increase the level of suicide precaution

Which term describes the clients' use of made-up words that have no meaning to other people? A: Avolition B: Echolalia C: Anhedonia D: Neologisms

D: Neologisms

When providing a change-of-shift report, which explanation would the nurse use to describe a schizophrenic client who is experiencing opposing emotions simultaneously? A: Double bind B: Ambivalence C: Loose Association D: Inappropriate Effect

B: Ambivalence Ambivalence is the existence of two conflicting emotions, impulses, or desires.

For a hyperactive, manic client who exhibits flight of ides, which rationale explains why the client is not eating? A: Feels undeserving of food B: Is too busy to take time to eat C: Wishes to avoid others in the dining area D: Believes that the food is poisoned

B: Is too busy to take time to eat

In the acute phase of bipolar disorder, manic episode, which bio-psychosocial need is the priority? A: Psychological B: Physical C: Intellectual D: Relational

B: Physical

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? A: Chess B: Writing C: Board games D: Group exercise

B: Writing

Which statement made by an assistive personnel (AP) indicates to the registered nurse that the AP understands the concepts related to suicide? 1. "Discussing suicide with a client is not harmful." 2. "Those clients who talk about suicide never do it." 3. "Depressed clients are the only persons who commit suicide." 4. "A suicide threat is a cry for attention from family and friends."

1. "Discussing suicide with a client is not harmful."

Which client is at greatest risk for committing suicide? 1. A client with metastatic cancer 2. A client with a newly diagnosed cardiac disorder 3. A client who just had an argument with her fiancé 4. A newly divorced client who states she has custody of the children

1. A client with metastatic cancer

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression? A: Restrict the client smoking for 12 hours. B: Enforce nothing by mouth (NPO) status for 16 hours. C: Limit the client's participation in unit activities for 24 hours. D: Assure that an electrocardiogram is performed within 24 hours.

D: Assure that an electrocardiogram is performed within 24 hours. Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate. The remaining options are incorrect.

The nurse is performing an admission assessment on a client at high risk for suicide. Which assessment question will best elicit data related to this risk? 1. "What are you feeling right now?" 2. "Do you have a plan to commit suicide?" 3. "How many times have you attempted suicide in the past?" 4. "Why were your attempts at suicide unsuccessful in the past?"

2. "Do you have a plan to commit suicide?"

The nurse is working at a Veterans Affairs clinic that provides services for homeless veterans. Which client should the nurse attend to first? 1. A client with a persistent cough 2. A client with a plan to harm himself 3. An amputee with an infected wound 4. A client with a history of substance abuse

2. A client with a plan to harm himself

The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? 1. Administer an antianxiety agent. 2. Assess and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.

2. Assess and treat the wound sites.