Mental Health B

A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make?

"Clients who are admitted involuntarily maintain the right to give informed consent for procedures."

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?

"I will not take charge of my partner's work responsibilities."

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching?

"I will talk about my feelings with a close friend."

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will update the plan of care as a client's manifestations of depression change."

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make?

"I'll stay with you just in case you want to talk."

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching?

Apply restraints when other means of managing the client's behavior have failed.

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?

Ask group members to discuss their feelings about this client's monopolizing behavior.

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?

Call for a team of staff members to help with the situation.

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others?

Command hallucinations

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?

Identify signs of escalation of violence.

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include?

Early identification of changes, such as decreased social involvement, is important.

A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team?

Giving away possessions

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan?

Identify the client's trigger foods.

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider?

Inability to sleep

A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in the situation?

Nonmaleficence

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?

Renew the prescription for the client every 4 hr.

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

Rhinorrhea

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

Suggest forming a weekly support group for parents who have experienced the death of a child.

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?

The client has COPD.

A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer?

1.5 mL

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make?

"It appears as though you would like to open the door."

A nurse in an emergency department is caring for a female adolescent who has diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis?

"She won't let me take the trash from her room. I'm concerned about what she has in there."

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent?

A 35-year-old client who has major depressive disorder

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effect?

Acute dystonia

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse?

An older adult client who is bedbound and has a stage IV pressure ulcer

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?

Assertive community treatment

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Assist the client with deep-breathing exercises.

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

Blood pressure 154/96 mm Hg

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

Establish screening programs to identify at-risk clients.

A nurse in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?

Experiences feelings of isolation

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should teh nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)?

Lack of interest in an upcoming holiday

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction?

Phenylephrine

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?

Offer the client high-calorie finger foods frequently.

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?

Older children who are responsible for their younger siblings

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care?

Permit the client to perform daily rituals to decrease anxiety.

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?

Reduce environmental stimuli.

A nurse on a mental health unit s caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?

Spending adequate time with a client who is verbally abusive

A nurse in a mental health clinic is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Stay with a client who has anorexia nervosa for 1 hr after mealtimes.

A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment. Which of the following is the priority action for the nurse to take?

Stay with the client when flashbacks occur.

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following finds as an adverse effect of methylphenidate?

Tachycardia

A nurse is discussing a 12 step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?

The client should obtain a sponsor before discharge for an increased chance of recovery.

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?

Tooth erosion

A nurse at a provider's office is interviewing an older adult client. Which of the following actions should the nurse plan to take?

Use a screening tool to evaluate the client for depression.

A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who is experiencing delusions of persecution

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse plan to see first?

A client who is taking clozapine and reports a sore throat and chills

A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness?

"I am going to order a wheelchair for when I'm unable to walk."

A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness?

"It is important for our child to have regular dental checkups."

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make?

"Let's take about what is upsetting you."

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?

"You're saying that you think you are fat and using laxatives because you are afraid of gaining weight."

A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate?

-Occupational therapy -Meal delivery services -Physical therapy -Home health services

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?

Easily distracted

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect?

Greater risk of attempting suicide as affect and energy improve

A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members.

Guided imagery

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?

Increased creatine phosphokinase (CPK)

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first?

Inform the client that this admission is confidential.

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

Language delay

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

Mild

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan?

Monitor the client's cardiac rhythm during the procedure.

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take?

Move the client who has bipolar disorder to a private room.

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine?

WBC count 2,500/mm3