Exam 2 MH
A client has been prescribed an antipsychotic medication for the management of symptoms associated with schizophrenia. Which behaviors will show improvement as a result of adhering to the medication therapy? (Select all that apply.) Fears being abducted by alien creatures Acknowledges regularly hearing voices Regularly discusses his or her alter identity as a spy for Hitler Consistently avoids the dayroom when other clients are there Stays in his or her room most of the day staring out the window
Acknowledges regularly hearing voices Regularly discusses his or her alter identity as a spy for Hitler
A nurse managing the care of a client diagnosed with an eating disorder has begun to experience frustration when the client consistently pushes back against the planned interventions. What action on the part of the nurse is indicated to help strengthen the nurse-client relationship? Demonstrating a very matter-of-fact attitude when addressing issues related to interventions Acknowledging to the client that working toward these treatment goals must be very frightening Regularly sharing with peers the feelings and asking for their suggestions on minimizing the frustration Incorrect Asking that a more experienced nurse be allowed to act as monitor in order to identify any existing countertransference
Acknowledging to the client that working toward these treatment goals must be very frightening
When planning a substance abuse information program for a local university, the nurse will prioritize which screening? Alcohol Inhalants Stimulants Hallucinogens
Alcohol
A mental health nurse assesses a patient diagnosed with an anti-social personality disorder. Which comorbid problem is most important for the nurse to include in the assessment?
Alcohol use and abuse
When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager? A. "On a regular basis, do you get enough restful sleep?" B. "Are you experiencing a flashback of the rape right now?" C. "Am I correct to say that you try to avoid certain family members?" D. "Can we discuss what triggered your angry outburst a few minutes ago?
B. "Are you experiencing a flashback of the rape right now?"
Which stress management behavior is most reflective of those associated with personality disorders? A. Binge drinking every weekend B. Demonstrating ritualistic behaviors C. Blaming spouse for the client's poor performance at work D. Having difficulty making a decision concerning which movie to view
Blaming spouse for the client's poor performance at work
To monitor for a significant health risk, the nurse will prepare to implement which intervention for a client admitted for alcohol detoxification? 24-hour urine test Cardiac consult Nutritional consult Falls assessment
Cardiac consult
Which nursing intervention will best address the intense need to control demonstrated by a client receiving treatment of bulimia nervosa? Monitoring the client for the presence of suicidal thoughts and behaviors Helping the client reframe irrational thinking that leads to dysfunctional eating Clearly stating expectations and admitting that they differ from those of the client Having the client keep a journal that identifies triggers that cause dysfunctional eating
Clearly stating expectations and admitting that they differ from those of the client
the nurse conclude that the treatment plan for a client diagnosed with a dissociative disorder best demonstrates success when which observation is made? A. The client agrees to adhere to interventions identified in the treatment plan B. Client engages in productive discussions related to childhood trauma C. Reports of physical pain have lessened substantially D. Client regularly attends assertiveness training group Incorrect
Client engages in productive discussions related to childhood trauma
Which assessment data confirms that the client diagnosed with anorexia nervosa has achieved a fundamental treatment outcome? Acknowledges that symptoms of depression exist Client has eaten 60% of three meals per day for 3 consecutive weeks Incorrect Client has maintained weight at 87% of ideal body weight for 2 months Demonstrates an understanding of what constitutes healthy eating habits
Client has maintained weight at 87% of ideal body weight for 2 months
The nurse is managing a group of clients diagnosed with somatic symptom disorders. Which client behavior best demonstrates the nurse's ability to manage manipulative behaviors therapeutically? A. All clients attend assertiveness training daily B. Clients direct all requests to a designated nurse C. Clients are involved in their personal discharge planning Incorrect D. Each client is aware of the role stress plays in his or her behaviors
Clients direct all requests to a designed nurse
A patient smiles broadly at the nurse and says, "Look at my clean teeth. I brushed them with scouring power because the label said 'it brightens and whitens everything'" Which term should the nurse include when documenting this encounter? A. Circumstantiality B. Concrete thinking C. Poverty of speech D. Associative looseness
Concrete thinking
A patient has a long history of bipolar disorder with frequent episodes of mania secondary to stopping prescribed medications. The patient says, "I will use my whole check next month to buy lottery tickets. Winning will solve my money problems." Select the nurse's best action. a. Educate the patient about the low odds of winning the lottery. b. Present reality by saying to the patient, "That is not good use of your money." c. Confer with the treatment team about appointing a legal guardian for the patient. d. Tell the patient, "If you buy lottery tickets, your money will run out before the end of the month."
Confer with the treatment team about appointing a legal guardian for the patient
Which assessment data for a client prescribed a psychotropic medication is a risk factor for developing autonomic dysfunction? Male 23 years of age Diagnosed as depressed Also prescribed dantrolene
Diagnosed as depressed
A client recently diagnosed as being obese is experiencing stress related to the need to lose weight. How can the nurse best help the client focus on the eustress nature of this stressor? A. Discuss weight loss strategies with the client B. Encourage the client to discuss his or her feelings about being obese C. Provide the client with a list of realistic, time focused on weight loss goals D. Re-enforce for the client that obesity is a health problem that is manageable
Discuss weight loss strategies with the client
The nurse is managing care for a client who is reporting increased stress related to a new work-related position. What intervention suggested by the nurse is associated with the effects of stress on the hypothalamus-pituitary-adrenal cortex? A. Drinking sufficient fluids to stay well hydrated B. Monitoring heart and respiratory rates daily C. Adding Vitamin C to the daily diet D. Being screened for depression
Drinking sufficient fluids to stay well hydrated
A patient diagnosed with bipolar disorder lives in the community and is showing early signs of mania. The patient says, "I need to go visit my daughter but she lives across the country. I put some requests on the Internet to get a ride. I'm sure someone will take me." What is the nurse's most therapeutic response? a. "I'm concerned about your safety when meeting or riding with strangers." b. "Have you asked friends and family to donate money for your airfare?" c. "You are not likely to get a ride. Let's consider some other strategies." d. "Have you asked your daughter if she wants you to come for a visit?"
I'm concerned about your safety when meeting or riding with strangers
Recognizing that somatic symptom disorders focus on physical symptoms, which client statement best demonstrates the unique characteristic of this type of disorder? A. "I wonder if my fear of cancer is real or imagined." B. "The pain I feel is nearly constant and very specific." C. "I've been to so many doctors but none can find out what's wrong with me." D. "For a while medication helped but now my stomach problems are back again."
I've been to so many doctors but non can find out what's wrong with me
A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa? a. "I look good because whenever I overeat, I purge myself." b. "I love sweets. I make myself throw up so I can eat more." c. "I've lost 60 pounds but I'm still a size 2. I want to be a size 0." d. "I've hidden my eating disorder from everyone, even my parents."
I've lost 60 pounds but I'm still a size 2. I want to be a size 0
Which intervention is best associated with minimizing the effects of dementia-induced aphasia? Increasing reliance on nonverbal communication methods Speaking in a slow, deliberate manner Delivering information in short, simple phrases Engaging in reminiscing therapy by focusing on familiar topics
Increasing reliance on nonverbal communication methods
A nurse plans care for a patient diagnosed with borderline personality disorder. Which nursing diagnosis is most likely to apply to this patient?
Ineffective relationships related to frequent splitting(Defense mechanism used frequently by people diagnosed with borderline personality disorder.)
A young adult tells the nurse, "I have a new prescription for medical marijuana. I use it several times a day for my frequent muscle spasms." What information should the nurse provide first to this patient? a. The guidance that the prescription should not be shared with peers b. Directions to weigh self once a week and maintain a log of the results c. Instructions about safety issues associated with driving or operating machinery d. Information about the potential for a motivational syndrome and memory problems
Instructions about safety issues associated with driving or operating machinery
A patient in the emergency department was seen for the third time in a month with complaints of tremors and paresthesia in the lower extremities. Conversion disorder was diagnosed. While preparing for discharge, the patient says, "Now I'm having chest pain but it's probably nothing." How should the nurse respond? A. Assess the patient's most current lab values. B. Interrupt the discharge and arrange additional medical evaluation of the patient. C. Remind the patient, "The diagnostic tests showed you did not have a medical problem." D. Tell the patient, "Being in the ER a long time can be very distressing.
Interrupt the discharge and arrange additional medical evaluation of the patient
Which statement by a client scheduled for a series of electroconvulsive therapy (ECT) treatments indicates to the nurse that the client has an understanding of the goals of this treatment? "It is expected that my chance for remission is very good." "If this works, I will likely be able to stop taking lithium." "I'm prepared to deal with the certain loss of my short-term memory." "My prognosis is so much better since I didn't have any delusional symptoms."
It is expected that my chance for remission is very good
Which behavior is most characteristic of a client diagnosed with antisocial personality disorder? Justifying taking another client's dessert by stating, "I deserve two desserts." Throwing a book when asked to turn down the volume on the television. Insisting that it is necessary to eat only green foods on Thursdays. Repeatedly accusing the staff of favoring another client.
Justifying taking another client's dessert by stating, "I deserve two desserts."
a patient experiencing depression says to the nurse, "my health care provider said i need talk therapy but i think i need a prescription for an antidepressant medication. What should i do?" Select the nurses best response a. which antidepressant medication do you think would be helpful b. there are different types of talk therapy. Most patients find it beneficial c. lets consider some ways to address your concerns with your health care provider d. are you willing to give talk therapy a try before starting an antidepressant medication
Lets consider some ways to address your concerns with your health care provider
A patient at a general medical clinic tells the nurse, " I have so many aliments that I need to see six different doctors. None of them has discovered what is really wrong with me." Which comment should the nurse offer next? A. "Let's review all of the medications you currently take." B. "Tell me about allergic reactions you've had to medications." C. "Selecting one primary care provider would be better for you." D. "I'm not sure I understand how you can afford these expenses."
Lets review all of the medications you currently take
The nurse at a local medical clinic reviews phoned-in requests from patients for prescription refills. As the nurse confers with the health care provider about which prescription refill requests should be authorized, which refill request should be considered first? a. Codeine 10 mg PO q4h PRN for an adult with a persistent cough b. Hydroxyzine (Vistaril) 25 mg PO TID PRN for an adult who experiences uncomfortable muscle spasms c. Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for episodes of anxiety d. Paregoric (camphorated tincture of opium) 2 mg PO q6h PRN for an adult experiencing severe diarrhea
Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for episodes of anxiety
Buspirone (Buspar)
Management of anxiety disorders. Non-addictive; excellent for long term relief of anxiety symptoms.
A client diagnosed with depression has been prescribed various first-line antidepressant agents but has demonstrated only minimal improvement. In preparation for the prescription of a second-line agent, the nurse will educate the client on which classification of antidepressant? Atypical Tricyclic Dual action Monoamine oxidase inhibitors
Monoamine oxidase inhibitors
When a client demonstrates symptoms associated with delirium, the nurse institutes care focused on the prevention of which result? Hallucinations Disorientation Impaired memory Neurological damage
Neurological damage
What classic characteristic is noted in clients diagnosed with bulimia nervosa? Male Obesity Involved in sports Onset in late adolescence
Onset in late adolescence
dual action reuptake inhibitor (SNRI) antidepressants
Panic disorder, generalized anxiety disorder (GAD), and social affective disorder (SAD)
While weighing patients on an eating disorders unit, the nurse overhears a psychiatric technician say, "I wish I had an eating disorder; maybe I'd lose a little weight." What is the nurse's best action? a. Report the clinical observation to the nursing supervisor. b. Ask the psychiatric technician, "What did you mean by that comment?" c. Privately discuss the importance of sensitivity with the psychiatric technician. d. Immediately interrupt the interaction between the patient and psychiatric technician.
Privately discuss the importance of sensitivity with the psychiatric technician
Which nursing intervention has priority during the acute phase of a client's manic episode? Providing fluids frequently to promote hydration Monitoring the amount of sleep the client achieves Identifying triggers for exacerbation of manic behavior Including family in regular counseling and therapy sessions
Providing fluids frequently to promote hydration
Which life event related to a client demonstrating depressive symptoms supports a diagnosis of persistent depressive disorder (PDD)? Abruptly ended a long-term romantic relationship Lost employment as a result of frequent absences 2 unsuccessful suicide attempts over the last year Recognized symptoms of depression over 2 years ago
Recognized symptoms of depression over 2 years ago
An adult required a heart transplant 5 years ago. Multiple medical complications followed, resulting in persistent irritability, depression, and insomnia. The adult's spouse says, "I've walked on eggshells for five years, never knowing when something else will go wrong." What is the nurse's priority intervention regarding the spouse? a. Explore the spouse's feelings, showing care and compassion. b. Encourage the spouse to attend a community support group. c. Teach stress reduction and relaxation techniques to the spouse. d. Refer the spouse to the primary care provider for health assessment.
Refer the spouse to the primary care provider for health assessment
MAOIs
Reserved for treatment-resistant conditions due to risk of life-threatening hypertensive crisis. Recently being used in people with a social anxiety disorder and rejection sensitivity.
An adult diagnosed with stage 2 Alzheimer's disease begins a new prescription for rivastigmine (Exelon). Which nursing diagnosis has the highest priority to add to the plan of care? a. Risk for constipation b. Risk for altered sensory perception c. Risk for impaired oral mucous membranes d. Risk for imbalanced nutrition, less than body requirements
Risk for imbalanced nutrition less than body requirements
Which teaching focused intervention will have the greatest impact on reducing the risk of relapsing for a client diagnosed with bipolar disorder? Symptom recognition Stress management skills Role of family as support Available social resources
Role of family as support
An outpatient psychiatric nurse assesses a patient diagnosed with hoarding disorder. The patient has lost 12 pounds in the past two months, appears disheveled, and is wearing dirty clothing with poor hygiene. What is the nurse's priority action? a. review the patient's medication regimen b. ask the patient, "What types of foods have you been eating?" c. refer the patient to a psychologist for cognitive behavior therapy (CBT) d. schedule a home visit to assess the safety of the patient's living conditions
Schedule a home visit to assess the safety of the patients living conditions
Tricyclic Antidepressants (TCAs)
Second or third-line use for PD, GAD, and SAD; clomipramine is effective in OCD
Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder? Educating the client to the policies upon admission to the unit Instructing the client that intrusive behaviors are not appropriate Setting and maintaining consistent unit policies that are enforced by all staff Ensuring that the client's medication therapy is administered in a timely manner
Setting and maintaining consistent unit policies that are enforced by all staff
The nurse will encourage the client to engage in regular involvement with which formalized groups as an intervention directed toward the treatment of a primary risk factor associated with depression? (Select all that apply.) Church associated men's group The sexual assault survivors group Senior citizens travel group New moms support group Alcoholics Anonymous (AA)
Sexual assault survivors groups. new moms support group, Alcoholic Anonymous (AA)
A community mental health nurse counsels a group of patients about the upcoming flu season. What instruction does the nurse provide for patients who are prescribed lithium? a. "Stop taking your medicine and contact me if you have nausea, vomiting, and/or diarrhea." b. "Remember that lithium reduces your immunity, so you are more vulnerable to catching the flu." c. "The flu is contagious. Isolate yourself if you get the flu so that you avoid exposing others to it." d. "Because you take lithium, you may have flu symptoms that are not typically experienced by others."
Stop taking your medicine and contact me if you have nausea, vomiting , and/or diarrhea
Which intervention will the nurse include in the plan of care to address a common comorbid condition demonstrated by many clients diagnosed with body dysmorphic disorder (BDD)? A. Suicide precautions B. Anger management group C. Frequent re-orientation to time and place D. Set and enforce reasonable limits regarding boundaries
Suicide precautions
Which nursing intervention is generally included in the plan of care for any hospitalized client experiencing a psychotic episode associated with schizophrenia? Identifying theme of hallucinations Suicide precautions per institution policies Boundary setting to manage aggressiveness Assessing for the presence of feelings of guilt
Suicide precautions per institution policies
A nurse is planning interventions for a veteran who has recently been discharged from the military and is reporting difficulty sleeping. When considering the client's past medical history, which data is most relevant to the development of posttraumatic stress disorder (PTSD)? A. Family history of depression B. Quit smoking tobacco two months ago C. Regularly smoked marijuana as a teenager D. Sustained a concussion a month before discharge
Sustained a concussion a month before discharge
An individual lives in a community adjacent to a military base. Loud jets fly overhead multiple times daily. The person tells the nurse, "They're so loud I can't hear myself think." What is the nurse's best first action? a. Direct the individual to report the jet noise to local authorities. b. Teach relaxation and stress reduction techniques to the individual. c. Assess the individual for sensory impairments, particularly auditory. d. Encourage the individual to form a community action group to oppose noise pollution.
Teach relaxation and stress reduction techniques to the individual
Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worst thing in the world. I hope it never happens to me." Which response by the nurse is appropriate? a. "You need to gain weight to become healthier." b. "Your world would not change if you gained a few pounds." c. "Tell me how your world would be different if you were fat." d. "Your attractiveness is not defined by a number on the scales."
Tell me how your world would be different if you were fat
When considering substance abuse, which individual is at the greatest risk for developing functional deficits in the future? The 15-year-old abusing cannabis The 28-year-old with a cocaine habit The 45-year-old with a 10-year history of heroin abuse The 60-year-old who has been dependent on sedatives for 15 years
The 15-year-old abusing cannabis
A client demonstrating delusional behavior is escalating as a result of increasing anxiety regarding his or her safety. Which action demonstrates that the client has an understanding of actions to de-escalate his or her anxiety? The client retreats to his or her room accompanied by staff The client asks that he or she be allowed to seclude him- or herself The client engages in a group therapy session led by nursing staff The client expresses the understanding that his or her safety is the primary nursing goal
The client asks that he or she be allowed to seclude him- or herself
A nursing student arrives late for clinical experience and is not wearing the correct attire. When the instructor privately criticizes the behavior, the student nurse responds, "I'm always the one who gets caught. You're going to cause me to fail." Select the instructor's best response a. "Other students get caught as well" 'b. "I am not trying to cause you to fail. I am here to help you" c. "I am sorry you feel that way. I try to treat all my students equally" d. "The requirements for this experience were discussed during our orientation"
The requirements for this experience were discussed during our orientation
A college student has been experiencing significant stress associated with academic demands. Last month, the student began attending yoga sessions three times a week. Which outcome indicates this activity has been successful? a. The student reports improved feelings of well-being. b. The student increases use of caffeine to enhance concentration. c. The student reports, "Now I am sleeping about 10 hours every day." d. The student says, "I withdrew from two courses to reduce my academic load."
The students reports improved feelings of well being
A patient diagnosed with schizophrenia says " i hear voices every day. they always say bad things about me" which action by the nurse has the highest priority a. assess the pt for suicidal thinking and plans b. review the pts med regime and compliance c. educate the pt about symptoms associated with schizophrenia d. suggest distracters for the pt to use when auditory hallucinations occur
assess the pt for suicidal thinking and plans
A patient tells the nurse, "After many years, I finally quit smoking. Now I use e-cigarettes only." Which response should the nurse provide? a. "Using e-cigarettes is now more socially acceptable than using traditional cigarettes." b. "Congratulations on quitting, but e-cigarettes contain nicotine and other hazardous chemicals." c. "Nicotine is a powerful addiction. Quitting smoking is a big step toward adopting a healthier lifestyle." d. "I am glad you have quit smoking. Your loved ones will no longer be exposed to the hazards of secondhand smoke.
"Congratulations on quitting, but e-cigarettes contain nicotine and other hazardous chemicals."
An older client has been diagnosed with infection-induced delirium. Which statement by the nurse to the client's family best demonstrates an understanding of the disorder while addressing the family's concerns? "Delirium isn't permanent when treated appropriately. The prescribed medication should eliminate the infection causing the symptoms." "The symptoms of delirium can be very difficult to watch in a loved one. Try not to worry since the condition is not permanent." "Infections commonly cause delirium in older clients. You'll see improvement in just a few days." "The symptoms will come and go during the next few days. It's a common condition." Delirium can be a result of an infection especially among older adult clients. The condition is r
"Delirium isn't permanent when treated appropriately. The prescribed medication should eliminate the infection causing the symptoms."
Which statement made by a client receiving treatment for a substance abuse problem best indicates an understanding of relapse prevention? "I want so much to stop abusing." "My family has helped me so much in staying sober." "I abuse when I'm bored or lonely but now I know how to keep busy." "A good time always meant being with friends who abused like I did."
"I abuse when I'm bored or lonely but now I know how to keep busy."
Which statement indicates the existence of a codependent relation between a client diagnosed with substance abuse and their life partner? "All our savings have been spent on rehab treatment." "They are the love of my life but it's so hard living together." "I'm always so angry about how the addiction controls our lives." "Everyone knows about the addiction and it is so very embarrassing."
"I'm always so angry about how the addiction controls our lives."
Which statement made by the client demonstrates an understanding of the benefit of clozapine? "I'm less likely to develop a stooped, shuffling walk." "It will help keep me from developing type 2 diabetes." "It will provide me with some protection against a heart attack." "This medication cost less than the first-generation antipsychotic type
"I'm less likely to develop a stooped, shuffling walk."
The nurse assesses a new patient suspected of having a schizotypal personality disorder. Which assessment question is this patient most likely to answer affirmatively?
"Is anyone in your family diagnosed with a mental illness?"
An 84-year-old tells the nurse, "I do four or five number puzzles every day to keep my brain healthy and sharp." When considering a holistic approach to maintaining mental health, the nurse should respond: a. "It is more important for you to have physical activity every day." b. "Let's think of some other activities we can add to your daily routine." c. "Repetition of the same activity is not helpful for keeping your brain healthy." d. "There are some herbal preparations that will also help keep your brain sharp."
"Let's think of some other activities we can add to your daily routine."
Which statement by a nurse providing care for clients diagnosed with personality disorders demonstrates therapeutic management of manipulative client behavior? (Select all that apply.) "Tell me what triggered your angry response to what I said." Incorrect "The staff is responsible for determining unit rules that are fair to all clients." "Remember that all clients must follow the rules regarding the use of the telephone." "Missing group today means that you will not be able to attend the pizza party later." "Tell me what you are trying to accomplish by being so rude to the staff and other clients."
"The staff is responsible for determining unit rules that are fair to all clients." "Remember that all clients must follow the rules regarding the use of the telephone." "Missing group today means that you will not be able to attend the pizza party later."
After a power outage, a facility must serve a dinner of sandwiches and fruit to patients. Which comment is most likely from a patient diagnosed with a narcissistic personality disorder?
"You should have ordered a to-go meal from a local restaurant for me."(Narcissistic diagnosed consider themselves special and expect special treatment. Their demeanor is arrogant and haughty.)
A patient was diagnosed with bipolar disorder many years ago. The patient tells the nurse, "When I have a manic episode, there's always a feeling of gloom behind it and I know I will soon be totally depressed." What is the nurse's best response? a. "Most patients diagnosed with bipolar disorder report the same types of feelings." b. "Feelings of gloom associated with depression result from serotonin dysregulation." c. "If you take your medication as it is prescribed, you will not have those experiences." d. "Your comment indicates you have an understanding and insight about your disorder."
"Your comment indicates you have an understanding and insight about your disorder."
Which newly hospitalized patient should the nurse monitor closely for development of delirium? a. 48-year-old who usually drinks a six-pack of beer daily b. 68-year-old who takes aspirin 650 mg twice daily for arthritic pain c. 72-year-old who says, "I have a glass of wine every evening to stimulate my appetite." d. 78-year-old diabetic whose blood glucose levels are consistently greater than 250 mg/dL
48-year-old who usually drinks a six-pack of beer daily
The school nurse assesses four adolescents, all of whom outwardly appear healthy. Which adolescent meets one criterion for anorexia nervosa with mild severity? a. 5'2" tall; weight 104 pounds b. 5'7" tall; weight 110 pounds c. 5'5" tall; weight 114 pounds d. 5'8" tall; weight 127 pounds
5'7 tall; weights 110lbs
A veteran of the war in Afghanistan tells the nurse, "Everyday, something happens that makes me feel like I'm still there. My family has grown impatient with me. They say it's time for me to move on from that time in my life but I can't." What is the nurse's first priority? a. Assess the veteran for suicide risk. b. Refer the veteran for specialized mental health services. c. Assess the veteran for evidence of traumatic brain injury. d. Refer the veteran's family to a posttraumatic stress disorder group.
Assess the veteran for suicide risk
When considering comorbid conditions, which nursing intervention is most appropriate for a client diagnosed with a dissociative disorder? A. Assessing client for suicidal ideations frequently during the day B. Administering medication to manage constipation as prescribed C. Inspecting skin for signs of damage resulting from repetitive hand washing D. Preparing for diagnostic testing to evaluate client's report that, "my heart skips beats"
Assessing client for suicidal ideations frequently during the day
A patient is hospitalized with a diagnosis of anorexia nervosa. The nurse reviews the patient's laboratory results below. Sodium 143 mEq/L Potassium 3.1 mEq/L Chloride 102 mEq/L Magnesium 2.2 mEq/L Calcium 8.4 mg/dL Phosphate 3.0 mg/dL The nurse should take which action next? a. Measure the patient's body temperature. b. Inspect the patient's skin and sclera for jaundice. c. Assess the patient's mucous membranes for erosion. d. Auscultate the patient's heart rate, rhythm, and sounds.
Auscultate the patients heart, rate, rhythm, and sounds
Lithium is prescribed for a client admitted with a diagnosis of bipolar disorder. Which other therapy is also initially prescribed to temporarily help manage the client's symptoms? Antimanic medication Antipsychotic medication Electroconvulsive therapy (ECT) Cognitive behavioral therapy (CBT)
Antipsychotic medication
A person shoplifts merchandise from a community cancer thrift shop. When confronted, the thief replies, "All this stuff was donated, so I can take it." This comment suggests features of which personality disorder?
Antisocial Disorder
Which nursing assessment question is focused on evaluating clients diagnosed with anxiety disorder for the most prevalent comorbid mental illness issue among this population? A. "Can you tell me the names and ages of your grandchildren?" B. "Are you currently experiencing any suicidal ideations?" C. "Are you hearing voices that no one else can hear?" D. "Do you ever engage in binge eating?"
Are you currently experiencing any suicidal ideations
A nurse begins a therapeutic relationship with a patient diagnosed with schizophrenia. The patient has severe paranoia. Which comment by the nurse is most appropriate? A. "Lets begin by talking about the goals you have for yourself" B. "I understand that you have problems with fear and suspiciousness of others" C. "As you get to know me better, I hope you will feel comfortable talking to me" D. "I am part of your treatment team. Our goal is to help stabilize your symptoms"
As you get to know me better, I hope you will feel comfortable talking to me
a patient diagnosed with schizophrenia complains to the nurse about persistent feelings of restlessness and says "i feel like i need to move all the time" whats nurses next reaction a. add an activity group to the pts plan of care b. assess the pt for other EPS c. perform a full mental status evaluation of the pt d. educate the pt about psychomotor agitation associated with schizophrenia
Assess the pt for other EPS
over the past 2 months a patient made eight suicide attempts with increasing lethality. The health care provider informs the patient and family the ECT is needed. The family whispers to the nurse, "isn't this a dangerous treatment?" How should the nurse reply? a. our facility has an excellent record of safety associated with use of ECT b. your family member will eventually be successful with suicide if aggressive measures are not promptly taken c. yes, there are hazards with ECT. You should discuss these concerns with the health care provider d. ECT is very effective when urgent help is needed. Your family member was carefully evaluated for possible risks
ECT is very effective when urgent help is needed. Your family member was carefully evaluated for possible risks
Which intervention associated with bipolar disorder best minimizes the risk for the development of suicidal ideations? Early diagnosis Family counseling Medication therapy Stress identification
Early diagnosis
What is the foundational principle to consider when assessing clients from varying ethnic cultures for behaviors associated with anxiety disorders? A. Asian Americans are least reluctant to seek psychiatric help B. There are basic anxiety driven behaviors demonstrated by all cultures C. Anxiety triggers somatic symptoms more prevalently than cognitive ones Incorrect D. Effective diagnosis of anxiety is dependent on an awareness of cultural norms
Effective diagnosis of anxiety is dependent on an awareness of cultural norms
A mature, professional couple plans a large wedding in a city 100 miles from their home. Which response is most likely to be associated with this experience? a. Distress b. Eustress. c. Acute stressed. d. Depersonalization
Enstress
A 28-year-old second-grade teacher is diagnosed with major depressive disorder. She grew up in Texas but moved to Alaska 10 years ago to separate from an abusive mother. Her father died by suicide when she was 12 years old. Which combination of factors in this scenario best demonstrates the stress diathesis model? a. cold climate coupled with a history of abuse b. the current age of 28 coupled with a family history of depression c. family history of mental illness coupled with a history of abuse. d.female gender coupled with the stressful profession of teaching
Family history of mental illness coupled with a history of abuse
Selective Serotonin Reuptake Inhibitors (SSRIs) (pram, tine)
First line treatment for anxiety disorders, OCD, and BDD
Which nursing intervention best meets the unique needs of the client diagnosed with delirium? Keeping environment well lighted Reassuring the client during periods of fearfulness Frequently assessing level of consciousness and orientation Concisely explaining why an intervention is going to occur
Frequently assessing level of consciousness and orientation
What assessment history data indicates that a client is at increased risk for developing Alzheimer's disease (AD)? Currently being treated for anorexia nervosa Has sustained two serious concussions Re-occurring bladder infections Current hypotension
Has sustained two serious concussions
How can the nurse manager on a mental health unit devoted to the care of clients diagnosed with personality disorders address the needs of the nursing staff? Design schedules to provide staff with 3 consecutive days off each period Schedule monthly in-services on the management of this client population Require that nursing staff rotate to another nursing unit for 6 months every 24 months Hold a daily meeting to focus on communication between nursing and supervisory staff
Hold a daily meeting to focus on communication between nursing and supervisory staff
Which statement demonstrates a characteristic of depression-associated behaviors that is especially associated with children and adolescents? "I don't care that friends say I'm grumpy." "I'm so very sad since my sister died." "Life is no fun since I lost my sister." "I can't go on being so depressed."
I don't care that friends say I'm grumpy
A patient diagnosed with dissociative identity disorder is hospitalized on an acute care psychiatric unit after a suicide attempt. During a team meeting, which staff nurse's comment should prompt the nursing supervisor to intervene? A. "I have never taken care of a patient with this disorder." B. "I think this patient was misdiagnosed and probably has schizophrenia." C. "I find myself more fascinated and engaged with this patient than others." D. "I recently read an autobiographical book about someone with this problem."
I find myself more fascinated an engaged with this patient than others
Which statement reflects successful achievement of a therapeutic long-term goal for a client diagnosed with somatic symptom disorder? A. "I may have found a doctor who can really help me." B. "My husband is starting to believe I'm really in pain." C. "I haven't missed a day of work in the last 6 months." D. "My symptoms may not be signs of a serious cancer."
I haven't missed a day of work in the last 6 months
Which response is characteristic of the implementation of an immature defense mechanism? A. "I only steal from stores that overcharge for the products in the first place." B. "I'm not a bully; it's just that people are envious of how rich I am." C. Giving an expensive gift to someone who you took advantage of Incorrect D. Drinking alcohol to get the courage to ask for a salary increase
I only steal from stores that overcharge for the products in the first place
A nurse analyzes reports from four adult patients of frightening events they encountered. Which patient's report most clearly indicates that the resulting fear was mentally healthy? a. "I saw a large spider crawling along my kitchen wall" b. "I was at the mall when a gunman began firing an assault weapon" c. "I was at home when a storm with heavy thunder and lightening lasted over an hour" d. "I was trapped on an elevator that stropped between floors when the power went out"
I was at home when a storm with heavy thunder and lightening lasted over an hour
A nurse in an outpatient medical clinic talks to a patient with a long history of malingering and doctor-shopping. The patient continues to express complaints of multiple problems. Select the nurse's best comment to the patient. A. "The treatment team believes you would benefit more from seeing a mental health professional." B. "The treatment team discussed your case and wants to begin a special case management program for you." C. "Because you have a number of medications, it would be safer to have them all filled at the same pharmacy." D. "Diagnostic testing has shown no medical problems and you are using your fare share of health care services."
The treatment team discussed your case and wants to begin a special case management program for you.
A combat veteran from two tours of the war in Afghanistan tells the nurse, "Some guys in my unit have PTSD, but I never had any problems other than my hearing is not as good as it once was." Which explanation for this comment should the nurse consider? A. The veteran wants to demonstrate toughness and strength. B. The veteran shows indicators of derealization and depersonalization. C. The veteran may be rationalizing this reaction to the memories of combat. D. The veteran may have amnesia associated with the combat experience.
The veteran may have amnesia associated with the combat experience.
Which statement demonstrates a defense mechanism often implemented by clients diagnosed with a borderline personality disorder? "I'm so ashamed when I lose my temper." "There is nothing good I can say about my mother." "I can't go to group unless you go with me." "I've attempted suicide on three different occasions."
There is nothing good I can say about my mother
A nurse has worked on a mental health unit for an extended period of time. Which statement is best associated with behaviors demonstrated as a result of burnout? A. "These clients are like living with my mother and aunt." B. "I'm really looking forward to the day I can retire and travel." C. "I'm so tired; having a 4 day stretch off will be so wonderful." D. "The clients often behave in a manner that makes them unlikable."
These clients are like living with my mother and aunt
A nurse teaches a patient diagnosed with an alcohol addiction about a new prescription for naltrexone (ReVia, Vivitrol). Which comment by the patient indicates the teaching was effective? a. "This medicine will stop my cravings for alcohol." b. "I should take this medication only when I feel cravings to drink alcohol." c. "This medicine is one part of a bigger treatment plan to help me stay sober." d. "I should not use products that contain alcohol, such as cough medicine and aftershave lotion."
This medicine is one part of a bigger treatment plan to help me stay sober
Which patient behavior noted by the nurse supports the diagnosis of a severe level panic? A. Pacing nervously B. Reports being "too nervous to eat" C. Too preoccupied to respond when unit fire alarm is tested D. Repeatedly demands that the staff "make the voices stop saying those bad things"
Too preoccupied to respond when unit fire alarm is tested
While interacting with a 62-year-old adult diagnosed with a progressive neurocognitive disorder, the nurse observes that the adult has slow responses and difficulty finding the right words. What is the nurse's best initial action? a. Suggest words that the adult may be trying to remember b. Ask the adult, "Are you having problems saying what you mean?" c. Use silence to allow the adult an opportunity to compose responses. d. Discontinue the interaction to prevent further frustration for the adult.
Use silence to allow the adult an opportunity to compose responses
Which nursing assessment question is focused on determining the client's motivation for binge eating? "Does binging help you get the attention you need?" "Would you say that you are less depressed after binging?" "Are you less likely to hear voices while you are binging?" "Do you sleep better at least temporarily after binging?
Would you say that you are less depressed after binging?"
Which comment by a patient diagnosed with bipolar disorder best indicates the patient is experiencing mania? a. "I have been sleeping about 6 hours each night." b. "Yesterday I made 487 posts on my social network page." c. "I am having dreams about my father's death 8 years ago." d. "My appetite is so robust that I've gained 4 pounds in the past 2 weeks."
Yesterday I made 487 posts on my social network page
Select the best example of altruism a. after recovering from a gunshot wound, a police officer attends a local support group b. after recovering from open heart surgery, an individual plays tennis three times a week c. an individual who received a liver transplant volunteers at a local organ procurement agency d. an individual with a long standing fear of animals volunteers at a community animal shelter
an individual with a ling standing fear of animals volunteers at a community animal shelter
the nurse cares for a hospitalized adolescent diagnosed with major depressive disorder. The health care provider prescribes a low dose of antidepressants. In consideration of published warnings about the use of antidepressant medications in younger patients, which action should the nurse employ? a. notify the facility's patient advocate about the new prescription b. teach the adolescent about black box warnings associated with antidepressant medications c. monitor the adolescent closely for evidence of adverse effects; particularly suicidal thinking or behavior d. remind the health care provider about warnings associated with the use of antidepressants in children and adolescents
monitor the adolescent closely for evidence of adverse effects; particularly suicidal thinking or behavior
three days after beginning a new regime of haloperidol 10 mg BID, the nurse observes that a hospitalized pt is drooling, has stiff and extended extremities and has skin that is damp and hot to the touch. the pt has difficulty responding verbally to the nurse. what is nurses correct analysis and action in this situation a. a seizure is occurring; place the pt in a lateral recumbent position and monitor b. serotonin syndrome has developed; place an IV line and rapidly infuse D51/2NS c. neuroleptic malignant syndrome had developed; prepare the pt for immediate transfer to a medical unit d. an acute dystonic rx is occurring ;promptly administer an IM injection of Benadryl
neuroleptic malignant syndrome had developed; prepare the pt for immediate transfer to a medical unit
Benzodiazepines (anxiolytics) - end (pam)
prescribed for short term treatment only; not for patients with substance use problems
Friends invite an adult diagnosed with type 2 diabetes to go on a mountain hike next week. The adult replies, "I can't go because I don't have any hiking shoes." In actuality, this adult fears difficulty with blood glucose management during strenuous activity. Which defense mechanism is evident? a. displacement b. rationalization c. passive aggression d. reaction formation
rationalization
A patient tells the nurse, "no matter what i do i feel like there is always a dark cloud following me". Select the nurses initial action a. assess the patients current sleep and eating patterns b. explain to the patient :everyone feels down from time to time" c. suggest alternative activities for times when the patient feels depressed d. say to the patient "tell me more about what you mean by a dark cloud
say to the patient tell me more about what you mean by a dark cloud
A family member asks the nurse, "I know my uncle's Alzheimer's disease has progressed but is there any medication that can help him now?" Which response by the nurse is correct? a. "I'm sorry, but there are no medications that help with severe Alzheimer's disease." b. "Alzheimer's disease sometimes stabilizes. Let's hope that happens in this situation." c. "There are a few medications that may help. Let's discuss it with the health care provider." d. "It sounds like you're having difficulty accepting that your uncle's disease is irreversible. Would you like to talk about those feelings?"
there are a few medications that may help. Let's discuss it with the HCP
