Ls2 NCLEX comprehensive review mental health

The police arrive in the ER with a client who has a lacerated both wrists what is the initial nursing action?

Examine and treat the wound sites

The nurses performing a follow-up teaching session with the client discharged one month ago. The client is taking fluoxetine (Prozac) what information would be important for the nurse to obtain during the client visit is it regarding side and adverse effects of the med?

G.I. dysfunctions

The nurses administering risperidone to a client who is scheduled to be discharged before discharge which instruction should the nurse provide the client?

Get up slowly when changing positions

The nurse is describing the med side and adverse effects to a client whose taking oxazepam what information should the nurse incorporate in the discussion?

Increase fluids and bulk in the diet

The client receiving tricyclic antidepressant arrives at the mental health clinic which observation would indicate that the client is following the med plan correctly?

Pt arrives at the clinic neat and appropriate in appearance

The hospitalized client has begun taking bupropion (Wellbutrin) as an antidepressant agent the nurse understands that which is an adverse affect indicating clients taking an excessive amount of medication?

Sz's

The nurse notes a client with schizophrenia is receiving an antipsychotic med is moving her mouth protruding tongue and grimacing as she watches television. The nurse determines that the client is experiencing which med complication?

Tardive dyskinesia (tongue)

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

The adolescent gives away a DVD and cherished autographed picture of a performer

The nurses is reviewing the assessment data of a client admitted to the mental health unit the nurse notes at the admission nurse documented that the client is experiencing anxiety as a result of situational crisis nurse determines that this type of crisis could be caused by which event?

The death of a loved one

The client taking lithium reports vomiting abdominal pain diarrhea blurred vision tinnitus and tremors the lithium level is 2.5 this level is indicated of which finding?

Toxic

The nurses conducting initial assessment on a client in crisis when assessing the client precipitation of the precipitating event that led to the crisis what is the most appropriate question?

What leads you to seek help now

The client was schizophrenia has been started on med therapy with Clozapine The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication?

White blood cell count

A depressed client on an inpatient unit says to the nurse My family would be better off without me what is the nurses best response?

You sound very upset are you thinking of hurting yourself

The nurse is planning care for client being admitted to the nursing unit who attempted suicide which priority nursing intervention should the nurse include in the plan of care?

1to 1 suicide precautions

The client is admitted with recent history of severe anxiety following a home invasion and Robbery. During the initial assessment interview which statement by the client would indicate to the nurse the possible diagnosis of post traumatic stress disorder?

I keep reliving the robbery and I see his face everywhere I go and I might have died over a few dollars in my pocket.

The nurse observes that a client with a potential for violence is agitated pacing up and down the hallway and is making progress and belligerent gestures at other client which statement would be most appropriate to make to this client

You seem restless tell me what is happening

The clients medication sheet contains a prescription for Zoloft to ensure safe administration of the med how should the nurse administers the dose?

At the same time each evening

The nurses developing a plan of care for client in a crisis state when developing the plan the nurse should consider which factor?

A clients response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client

Okay is scheduled for discharge and will be taking phenobarbital sodium for an extended period. The nurse would place highest party and teaching client which point directly relates to pt safety?

Avoid drinking alcohol While taking this med

The client is admitted to the mental health unit after an attempted suicide by hanging the nurse can Best ensure client safety by which action?

Assigning a staff member to the client who will remain with the client at all times

I hospitalize client is started on phenelzine (Nardil) for the treatment of depression. The nurse should instruct the client that which foods are NOT acceptable to consume while taking this medication?

Figs yogurt aged cheese and oatmeal raisin cookies

Client gives the home health nurse a bottle of clomipramine (anafranil) nurse notes that the Med has not been taken by the client in two months which behavior observed in the client would validate noncompliance with this med?

Frequent handwashing with hot soapy water

The nurses teaching a class is being started on imipramine (tofranil) about the medication and the nurse should inform the client to expect maximum desired effects at what time period Following initiation of the med?

In 2 to 3 weeks

The emergency department nurse is caring for an adult client who is a victim of family violence which Priority instruction should be included in the discharge instructions?

Information regarding shelters

The nurse has been observing a client closely who has been displaying aggressive behaviors The nurse observes that the behavior displayed by the client is escalating which nursing intervention is least helpful to this client at this time?

Initiate confinement measures

The nurse in emergency departments caring for young female victim of Sexual assault. The client physical assessment is complete and physical evidence have been collected the nurse note that the client is withdrawn confusing at times physically immobile. how should the nurse interpret these behaviors?

Normal reactions to devastating event

Client who has been taking buspirone (buspar) for one month returns to clinic for follow-up assessment the nurse determines that the med is effective if absence of which manifestation has occurred?

Rapid heart beat or anxiety

Moderately depressed client who was hospitalized two days ago suddenly began smiling and reporting that the crisis is over the client says to the nurse im finally cured how should the nurse interpret this behavior as a cue to modify the treatment plan?

increasing the level of suicide precautions

The female victim of sexual assault is being seen in the crisis center the client states that she still feels as though the rape just happened yesterday even though it has been a few months since the incident what is the most appropriate nursing response?

tell me more about the incident that causes you to feel like the rape just occurred