mental health exam 2 practice questions

An individual calls the hospital during the night shift in crisis and is considering suicide. The nurse will begin the interaction by saying which assessment question? "How are you feeling today?" "How long have you been this way?" "Are you willing to let me help work this out?" "Who is there with you right now?"

"Are you willing to let me help work this out?"

An individual has taken Valium for the past 4 years and is considering discontinuing the medication. To ensure the patient's safety, what information should the nurse reinforce? "Anxiety seldom gets better without medication." "Diazepam should not be discontinued abruptly." "Buspirone is a better choice when anxiety also occurs." "It is important to remember not to mix alcohol with diazepam."

"Diazepam should not be discontinued abruptly."

Teaching a patient and family about buspirone would include which statement? "Expect some relief from your anxiety in about 7 to 10 days, but the full effect of this medication may take up to 6 weeks." "Be certain that you do not take more than your prescriber has ordered, because this medication can be addicting." "Your diazepam will be stopped immediately while the buspirone takes effect." "Buspirone will probably make you feel sleepy."

"Expect some relief from your anxiety in about 7 to 10 days, but the full effect of this medication may take up to 6 weeks."

A patient comes to the clinic for a 4-week follow-up after starting fluoxetine. What is the highest priority assessment question the nurse should ask? "How have you been sleeping?" "Did you drive to the clinic today?" "Has your stomach felt uncomfortable?" "Have you experienced thoughts of hurting yourself?"

"Have you experienced thoughts of hurting yourself?"

An older adult is reporting fatigue and periods when breathing is difficult. All examinations, lab, and diagnostic values are in acceptable ranges. The nurse will best initiate a discussion regarding the patient's emotional health by asking which assessment question? "What do you think is wrong with you?" "Are you depressed?" "How have you been feeling emotionally?" "Do you see yourself as being an anxious person?"

"How have you been feeling emotionally?"

Which assessment question will the nurse ask to help identify the cause of a patient's decreased lithium levels? "How much coffee do you drink daily?" "How much salt do you consume daily?" "Have you been prescribed a daily diuretic medication?" "Have you been taking any anti-inflammatory medications?"

"How much coffee do you drink daily?"

Which statement made by a severely depressed client reflects the greatest barrier to the nurse's goal of establishing and maintaining a working client-nurse relationship? "I'll talk we you later; I'm too tired right now." "I don't have any idea why I'm so depressed." "I don't see what good talking to you will do." "Nobody is really interested in what I have to say."

"I don't see what good talking to you will do."

An older adult who is diagnosed with dementia says, "I can't find my purse, and I think someone stole it!" What is the nurse's most therapeutic response? "How much money did you lose?" "You sound suspicious of the staff." "I will help you look for your purse." "Keep looking for it; I am sure you will find it."

"I will help you look for your purse."

Which statement is associated with the nurse's initial intervention when working with a patient experiencing extreme anxiety? "Slow, deep breathing will help you regain control." "Tell me what you need to manage your anxiety." "I will stay with you as long as you need me." "Let's talk about what triggered your anxiousness."

"I will stay with you as long as you need me."

Medication teaching regarding lithium is regarded as successful when the nurse hears the patient makes which statement? "Potassium can be dangerous in my diet." "My body treats lithium just like salt." "A multivitamin each day will be important." "I won't have to see the doctor for 3 months."

"My body treats lithium just like salt."

An older adult patient living in the community is taking an antipsychotic medication. Which statement made by the patient requires the nurse's priority intervention? "I am concerned about how much all these pills cost." "I cleaned my apartment yesterday." "All my medications are in this bag, so you can look at them." "My tongue and mouth feel really different this week."

"My tongue and mouth feel really different this week." Antipsychotic drug dosages for older adults tend to be 50% or less than those given to younger patients. Nurses must carefully monitor patients for side effects. Initiating an AIMS (Abnormal Involuntary Movement Scale) assessment and scoring to rule out tardive dyskinesia, causing repetitive, involuntary movements, such as grimacing and eye blinking, is of priority.

Which statement indicates that the patient with an anxiety disorder has developed a healthy coping strategy for dealing with sleep difficulties? "One or two beers really help me get to sleep." "I will call the doctor if I need more pills to sleep at night." "My neighbors are always available to talk to me through the night; I can call them anytime." "The student nurse taught me relaxation techniques that I will continue to use at home."

"The student nurse taught me relaxation techniques that I will continue to use at home."

A patient asks, "Why have I been prescribed a selective serotonin reuptake inhibitor (SSRI) rather than one of the other kinds of antidepressants?" The nurse addresses the patient's question best when providing which response? "This classification is usually effective and generally causes fewer side effects." "SSRIs are far less expensive than any other antidepressant." "Your mental health provider has determined that your symptoms will be best managed with this classification of antidepressants." "It sounds like you have some doubts about the effectiveness of this classification of antidepressants."

"This classification is usually effective and generally causes fewer side effects."

Which statement is most important for the nurse to include when caring for a patient who is currently experiencing a panic attack that involves perceived chest pain? "There is nothing physically wrong with you; you are just frightened right now because of all the anxiety you are feeling." Touch the patient lightly on the arm and say, "What's the matter?" "You are safe. I am here and will stay with you." "You may feel as though you are having a heart attack, but it is your anxiety causing your chest pain."

"You are safe. I am here and will stay with you."

The nurse is assessing a client who talks freely about feeling depressed. During the interaction, the nurse hears the client state, "Things will never change." What other indications of hopelessness would the nurse look for? 1. Bouts of anger 2. Periods of irritability 3. Preoccupation with delusions 4. Feelings of worthlessness 5. Self-destructive behavior 6. Auditory hallucinations

1 2 4 5

The nurse is assessing a client for dementia. What findings would the nurse expect a client with dementia? 1. There is a slow progression of symptoms. 2. The client admits to feelings of sadness. 3. The client acts apathetic and pessimistic. 4. The family can't determine when the symptoms first appeared. 5. There are changes in the client's basic personality. 6. The client has great difficulty paying attention to others.

1 4 5 6

A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? 1. Calcium 2. Sodium 3. Chloride 4. Potassium

2

After interviewing a client diagnosed with recurrent depression, the nurse determines the client's potential to commit suicide. Which factors would the nurse consider as contributors to the client's potential for suicide? 1. Psychomotor retardation 2. Impulsive behaviors 3. Overwhelming feelings of guilt 4. Chronic, debilitating illness 5. Decreased physical activity 6. Repression of anger

2 3 4 6

A client has been diagnosed with an adjustment disorder with mixed anxiety and depression. What are the primary nursing diagnoses associated with an adjustment disorder? 1. Activity intolerance 2. Impaired social interaction 3. Situational low self-esteem 4. Disturbed personal identity 5. Acute confusion 6. Impaired memory

2,3

A client diagnosed with anxiety disorder is prescribed buspirone (BuSpar). Teaching instructions for newly prescribed buspirone should include which of the following? 1. A warning that immediate sedation can occur with a resultant drop in pulse 2. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug 3. A warning about the incidence of neuroleptic malignant syndrome (NMS) 4. A warning about the drug's delayed therapeutic effect, which occurs in 14 to 30 days

4

Which nursing intervention would benefit an individual diagnosed with dementia who experiences short-term memory difficulties? An exercise group A reminiscence group A menu of favorite foods A daily activity schedule

A daily activity schedule

It has been determined that a patient is experiencing life-threatening toxicity related to tricyclic antidepressant (TCA) use. Which intervention will the nurse anticipate? Frequently assessing for suicidal ideations Administering the acetylcholinesterase inhibitor physostigmine (Antilirium) Inserting an indwelling urinary catheter Preparing the patient for an EEG

Administering the acetylcholinesterase inhibitor physostigmine (Antilirium) The antidote for severe TCA poisoning (anticholinergic toxicity) is physostigmine, an acetylcholinesterase inhibitor (inhibits the breakdown of acetylcholine).

Screening for symptoms of which mental health disorder is most appropriate for the older adult population? Major depression Anxiety Somatic disorders Phobia

Anxiety

Which nursing intervention is most appropriate for the post-crisis depression phase of the assault cycle? Asking "Can we talk about what triggered your angry behavior?" Applying physical restraints when deemed necessary Directing the client to "Go to your room and calm yourself " Providing prescribed medication

Asking "Can we talk about what triggered your angry behavior?"

When prescribed a benzodiazepine, a patient is considered to be at risk for falls mostly because of what common medication-related side effect? Ataxia Dysarthria Lassitude Retrograde amnesia

Ataxia Commonly, central nervous system side effects such as ataxia (decreased motor co-ordination) are exhibited and increase the patient's risk for falls

What presents the greatest postnatal risk to a newborn whose mother is now managing her bipolar disorder with lithium? Potential maternal neglect Breastfeeding Potential maternal abuse Infections

Breastfeeding

What is the priority nursing intervention when working with a patient who has entered the escalation phase of the assault cycle? Calling for the staff's help immediately Calling the patient by name while letting him or her know that the staff is there to help Administering PRN antianxiety medications by mouth as ordered Assisting the patient to identify and eliminate the trigger causing the anger

Calling the patient by name while letting him or her know that the staff is there to help

Growth hormone assessment is a frequently used biologic diagnostic tool to diagnosis depression in which population? Children Adolescents Middle-aged adults Older adults

Children

In evaluating medication ordered for an older adult experiencing mental illness, the nurse will expect the prescriber to make what action their priority? Beginning with a near-maximum dose and then titrating down if necessary Considering the hepatic and renal functioning of the individual Avoiding the use of medications for depression or anxiety Speaking to the caregiver rather than the older adult to minimize stress

Considering the hepatic and renal functioning of the individual

A patient is prescribed clonazepam for a panic disorder. Which additional medical condition would also benefit from this medication? Lower back spasms Alcohol withdrawal Convulsions Chemotherapy-induced nausea and vomiting

Convulsions

What symptom is associated with benzodiazepine withdrawal? Visual hallucinations Convulsions Cardiac arrest Respiratory arrest

Convulsions

Which personal factor has the greatest impact on a person's management of stressful events? Perception of the event Coping skills Life experiences Definition of stress

Coping skills

What is the most serious outcome for a patient who is experiencing the exhaustion stage of anxiety? Death Psychosis Disorganized personality Aggressive behavior

Death

nurse who understands the psychopathology of bipolar disorder will include which intervention into the client's care plan? Assist the patient in making frequent calls to friends and neighbors while on the inpatient unit. Distract the patient to avoid negative outcomes resulting from manic behavior. Provide frequent large meals to the patient who is experiencing flight of ideas. Promote the therapeutic relationship with humor and joking behaviors.

Distract the patient to avoid negative outcomes resulting from manic behavior. Therapeutic use of distraction is most helpful when a patient experiences acute mania and demonstrates the best understanding of the disease process.

Which assessment question is appropriate to identify a unique characteristic of a patient experiencing bipolar depression? "Do you experience insomnia on a regular basis?" "Have you experienced a weight loss recently?" "Have you ever been diagnosed with anorexia?" "Do you experience paranoid thoughts?"

Do you experience paranoid thoughts? Atypical depressions cause paranoid thoughts; other characteristic behaviors include hypersomnia not insomnia, hyperphagia not anorexia, and weight gain not weight loss.

During a shift report, the nurse learns that she will be providing care for a client who's vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as: 1. barbiturates. 2. antianxiety drugs. 3. depressants. 4. amphetamines.

During a shift report, the nurse learns that she will be providing care for a client who's vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as: 1. barbiturates. 2. antianxiety drugs. 3. depressants. 4. amphetamines.

Which group activity would best benefit individuals experiencing anxiety disorders while attending a community mental health clinic program? Cooking lessons Exercise classes A budget management seminar Visiting a museum

Exercise classes

Which assessment data would be inconsistent with a diagnosis of mania? The patient is demonstrating severe irritability. Family report that the mood change occurred gradually over a 5-day period. The behaviors have increased in severity since onset 2 weeks ago. The patient has been abusing alcohol consistently since onset of symptoms.

Family report that the mood change occurred gradually over a 5-day period. Manic episodes usually begin suddenly, escalate rapidly, and last from a few days to several months. To meet diagnostic criteria, the symptoms must persist for at least 1 week (or less if hospitalization is required).

A 70-year-old man comes to the clinic for his annual physical exam and influenza vaccine. He shares that his "life has no meaning," he "feels tired all the time," and "has lost all hope for the future." What should be the initial nursing intervention? Ask him to stay in the clinic until a mental health professional arrives to further assess him. Alert the physician that he may be depressed and require inpatient treatment. Further assess his concerns and history of psychiatric issues. Note that the patient is experiencing expected aging processes.

Further assess his concerns and history of psychiatric issues.

An individual taking benzodiazepines demonstrates an understanding of dietary consideration when expressing the need to avoid consuming what food or beverage? Dairy products Leafy green vegetables Grapefruit juice Cured meats

Grapefruit juice

Which behavior demonstrates the most lethal plan by an individual who has recently expressed suicidal ideations? Driving to the store and buys a bottle of aspirin. Hoarding a large number of barbiturates Cutting his or her wrists, then calling his or her significant other to say goodbye. Calling his or her therapist threatening to commit suicide.

Hoarding a large number of barbiturates

Which assessment data would support a diagnosis of bipolar II disorder? Hypomania Behaviors that span at least a 6-day period Paranoia Behaviors requiring hospitalization

Hypomania

A depressed patient originally responded to a failure by stating, "I can't do anything right." Which statement by the same client would demonstrate the successful implementation of negative thought reprogramming? "I'm a fairly accomplished cook." "I wish I wasn't so worried about how I look." positive self-esteem. "I'll try but I'm very done this before"a sense of personal worth. "I'll look at the want ads and see who's hiring." effective problem solving.

I'm a fairly accomplished cook.

When a patient is prescribed carbamazepine when lithium is ineffective at managing the symptoms of bipolar disorder, the nurse will include what information in the patient education plan? The possible development of a skin rash Symptom recognition of Stevens-Johnson syndrome May prevent weight loss Initially, complete blood counts (CBCs) will be scheduled weekly

Initially, complete blood counts (CBCs) will be scheduled weekly

A patient's lithium level is 2.3 mEq/L. Which nursing intervention will the nurse be prepared to implement when ordered? Managing the administration of parenteral normal saline Increasing the daily dose of lithium Limiting the patient's intake of sodium Preparing to administer an oral diuretic

Managing the administration of parenteral normal saline

Manic individuals often attempt to control others and to achieve their goals through which mechanism? Displaying tantrum-like behavior when frustrated Physically aggressive behavior directed toward others Manipulatively praising others to gain favor Threatening to physically harm themselves

Manipulatively praising others to gain favor

A patient has just completed electroconvulsive therapy. Which intervention is most important for the nurse to implement? Observe for disorientation. Ask the patient to state his or her name. Monitor the patient's respiratory status. Document the length of the seizure activity.

Monitor the patient's respiratory status

Which breakfast selections demonstrate that a patient understands the nurse's dietary instructions while taking monoamine oxidase inhibitor (MAOI) antidepressants? Bacon, eggs, cheddar cheese, and avocado slices in a flour tortilla Banana slices and raisins in whole-grain cereal with milk Blueberry pancakes with yogurt Oatmeal with almonds and milk

Oatmeal with almonds and milk

Which population is at greatest risk for experiencing a paradoxic reaction when prescribed a benzodiazepine? Males Those with a history of depression Older adults Those of Asian heritage

Older adults Children, older adults, patients with poor impulse control, and individuals with organic brain syndrome are most at risk for experiencing a paradoxic reaction to benzodiazepines

Which side effect of monoamine oxidase inhibitor (MAOI) therapy will the nurse be particular concerned about when this classification of antidepressants is prescribed to an older adult patient? Orthostatic hypotension resulting in falls Hypertension-induced strokes Hypertensive crisis resulting from eating tyramine-rich foods Drug-induced reflex tachycardia

Orthostatic hypotension resulting in falls

A patient diagnosed with Parkinson disease is at risk for demonstrating behaviors associated with which mental health disorder? Psychosis Bipolar II Simple phobia Schizophrenia

Psychosis

A patient has been expressing beliefs that are not in touch with reality. The nurse's decision not to challenge the patient concerning these delusions is based on the understanding that to do so would bring about what most likely outcome? Reinforcement of the delusion. Confuse the patient's sense of reality more. Increase the risk of psychotic behavior. Undermine the patient's sense of self-worth.

Reinforcement of the delusion.

Which class of medications is most often used long term to effectively treat generalized anxiety disorder (GAD)? Tricyclic antidepressants (TCAs) Benzodiazepines Nonbenzodiazepines Selective serotonin-norepinephrine reuptake inhibitors (SNRI)

Selective serotonin-norepinephrine reuptake inhibitors (SNRI)

A patient diagnosed with vascular dementia is engaged in a conversation with the nurse in the dayroom. When the nurse observes that he is becoming agitated, which intervention will help de-escalate the situation? Joke with the patient to defuse his anger. Bring other staff into the conversation to distract him. Turn the television on while redirecting his attention. Stop talking, and slowly back away from him.

Stop talking, and slowly back away from him.

Meeting the immediate safety needs of an aggressive patient is based on which principle of care? The safety of the milieu must be achieved by any means available. The least restrictive option is implemented. Patients in seclusion and/or restraints require intensive nursing care. Safety is a right of all patients.

The least restrictive option is implemented.

Which intervention demonstrates a need for further education regarding the effective use of physical restraints/seclusion? The release of physical limb restraints is initiated every 2 hours. Ten-minute range-of-motion exercises are implemented for each restrained extremity. The patient is allowed to listen to his or her personal radio during the isolation process. The staff has scheduled regular contact with the patient when restraints are in place.

The patient is allowed to listen to his or her personal radio during the isolation process.

What is the rationale for using benzodiazepines to detoxify patients diagnosed with chronic alcoholism? They prepare the patient for using prescribed drugs rather than alcohol. They allow for the gradual introduction of a less addictive substance. They permit the detoxification process to occur in a hospital setting. They significantly help manage the withdrawal symptoms.

They significantly help manage the withdrawal symptoms.

Which statement is true regarding pseudodementia when compared to true dementia? Pseudodementia symptoms are more severe than those of true dementia. Pseudodementia results in lower functioning abilities than does true dementia. True dementia is chronic in nature, while pseudodementia is highly treatable. True dementia does not always present with a depressed mood, but pseudodementia sometimes does.

True dementia is chronic in nature, while pseudodementia is highly treatable.

What assessment data confirms the presence of early, noticeable cognitive dysfunction generally noted in patients diagnosed with dementia? Claims having problems "finding the right word" Unable to remember date and day of the week Has a short attention span Usually is unable to recognize children or spouse

Unable to remember date and day of the week

In adapting interaction strategies while working with an individual with early Alzheimer disease, what is the priority nursing intervention? Speaking loudly and clearly Giving instructions slowly and repeatedly Using a calm and matter-of-fact tone Regularly providing reality orientation and reminders

Using a calm and matter-of-fact tone

It is most important for the nurse to include the client's significant others when teaching which aspect of bipolar self-care? The need to notify the health care provider when the client is facing a crisis situation The importance of eating a heart-healthy diet and exercising regularly Watching for and reporting impending signs of relapse such as sleeping difficulties and irritability Receiving credit counseling in the case the client's behavior has resulted in a large debt

Watching for and reporting impending signs of relapse such as sleeping difficulties and irritability

When comparing the needs of patients experiencing depression and those experiencing bipolar disorder, both groups will require which intervention? Careful monitoring of environmental stimuli Suicide and escape precautions Fall and seizure precautions Assessment of eating and sleeping patterns

assessment of eating and sleeping patterns

A patient's inability to de-escalate his aggressive behavior has resulted in the response team coming to the unit. When the patient demands to know, "Why are all these people here?", the nurse responds most therapeutically when making what statement? "You are out of control, and they are here to keep everyone safe." "They are here to make sure you are safely placed in the seclusion room." "We are here to keep you safe and stop you from hurting anyone else." "You are likely to hurt someone, and we can't allow that to happen."

"We are here to keep you safe and stop you from hurting anyone else."

A nurse making which statement demonstrates the best understanding of the pathophysiology associated with a panic attack when providing care to a client having such an experience? "The panic will pass faster if you focus on a pleasant past memory." "Physical exercise will help distract you while you are experiencing the panic." "You can trust that the anxiety you feel will go away in time." "The feeling of panic generally only lasts about 5 minutes."

"You can trust that the anxiety you feel will go away in time."

A client is admitted to the emergency department with chest pain, palpitations, vertigo, and diaphoresis. When initial assessment shows no physiological basis for these complaints, the client is referred to a psychiatric clinical nurse-specialist. After determining that the client has had four similar episodes in the last month, the specialist suspects that the client has: 1. panic disorder. 2. depression. 3. schizophrenia. 4. obsessive-compulsive disorder

1

Which of the following statements describes how elderly clients react to medications? 1. At risk for increased adverse effects 2. Tolerate medication better because they are less active 3. Metabolize medications quickly 4. Need higher doses than younger clients to respond to the same medication

1

In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, "How long do I have to stay here?" 1. "You may leave the hospital at any time unless you are suicidal." 2. "Let's talk more after the health team has assessed you." 3. "Once you've signed the papers, you have no say." 4. "Because you could hurt yourself, you must be safe before being discharged." 5. "You need a lawyer to help you make that decision." 6. "There must be a court hearing before you leave the hospital."

1,2,4

A client with the nursing diagnosis of Fear, related to being embarrassed in the presence of others, exhibits symptoms of social phobia. What should the goals be for this client? 1. Manage her fear in group situations. 2. Develop a plan to avoid situations that may cause stress. 3. Verbalize feelings that occur in stressful situations. 4. Develop a plan for responding to stressful situations. 5. Deny feelings that may contribute to irrational fears. 6. Use suppression to deal with underlying fears.

1,3,4

A 23-year-old client in the manic phase of bipolar disorder is admitted to the facility. Which agents would be appropriate for this client? 1. Bupropion (Wellbutrin) and lithium (Lithobid) 2. Lithium (Lithobid) and valproic acid (Depakote) 3. Haloperidol (Haldol) and fluphenazine (Prolixin) 4. Risperidone (Risperdal) and clozapine (Clozaril)

2

The physician orders lithium carbonate (Lithonate) for a client who's in the manic phase of bipolar disorder. During lithium therapy, the nurse should watch for which adverse reactions? 1. Weakness, tremor, and urine retention 2. Anxiety, restlessness, and sleep disturbance 3. Constipation, lethargy, and ataxia 4. Nausea, diarrhea, tremor, and lethargy

4

The nurse interviews the family of a client hospitalized with severe depression and suicidal ideation. What family assessment information is essential in formulating an effective care plan? 1. Physical pain 2. Personal responsibilities 3. Employment skills 4. Communication patterns 5. Role expectations 6. Current family stressors

4,5,6

Which depressed patient could most benefit from a trial prescription of bupropion? A older female adult with a history of epilepsy An underweight teenager A young male adult with a nicotine addiction A young female adult taking risperidone

A young male adult with a nicotine addiction

Which intervention by the nurse would help establish the nurse-patient relationship when conducting an assessment interview with a mentally ill older adult? Allowing adequate time for the patient to formulate answers to the questions Asking questions using common words and short sentences Avoiding unnecessary interruptions and distractions Addressing the patient by Mr, Mrs, or Miss and their last name

Addressing the patient by Mr, Mrs, or Miss and their last name

The nurse notes that a patient is often late to meals because of time needed to ritualistically wash and rewash his or her hands. In working with the patient to reduce stress, what intervention should the nurse implement? Announce to the patient, "your meal will be served in 30 minutes." Hold the meal, and discuss the problem during the next scheduled therapy group. Provide the patient with liquid meals to drink while performing the rituals. Remind the patient that the rituals are not helpful in recovery from the anxiety.

Announce to the patient, "your meal will be served in 30 minutes."Correct

A chronically depressed patient tells the nurse, "My antidepressant just doesn't seem to be working as well as it did." What is the nurse's initial assessment intervention? Determining whether the patient has been taking the medication as prescribed Asking the patient how long he or she has been taking this particular antidepressant Determining if the patient has been experiencing any physical side effects Asking the patient to describe what he or she means by "not working as well"

Asking the patient how long he or she has been taking this particular antidepressant

Which behavior best demonstrates a positive outcome for a client diagnosed with adjustment disorder with depressed mood? Attending therapies and activities on the clinical unit Asking to participate in the gardening group project Reading in the community area on the unit for most of the day Accepting visits with a spiritual leader while on the unit

Asking to participate in the gardening group project

Which intervention will best address the low self-esteem issues experienced by a middle-aged adult who has been unemployed for 2 years? Provide the patient with a regular bathing and grooming schedule. Listen attentively as the patient retells the details of being unemployed. Assist the patient in identifying personal skills and achievements. Encourage the patient to focus on retraining opportunities in the community.

Assist the patient in identifying personal skills and achievements.

Which behavior demonstrated by a patient diagnosed with Alzheimer disease supports the nurse's documentation that the patient is experiencing illusions? Responds to all questions by answering, "I have a headache." Becomes restless and agitated each afternoon just before dinner. Consistently insists that a child's doll is a real baby. Believes that all strangers are aliens from another planet.

Consistently insists that a child's doll is a real baby

A patient in acute mania is inappropriately humorous. Patients and staff are laughing at the patient's expense and embarrassment. What intervention should the nurse implement immediately? Distract the patient to engage in another activity apart from the group. Confront the group to stop the disrespectful behavior. Join the group, and further assess the situation. Consult the multidisciplinary team to determine the behavioral consequences for the staff.

Distract the patient to engage in another activity apart from the group. Utilizing the distractibility of the patient therapeutically and advocating in removing the patient from the embarrassing situation should take priority.

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? "You sound very upset. Are you thinking of hurting yourself?"

Prior to initiating a tricyclic antidepressant (TCA), the nurse should evaluate which of the patient's diagnostic tests? Electroencephalogram (EEG) Electrocardiogram Lipids Complete blood count (CBC)

Electrocardiogram

The nurse learns that a patient prescribed a benzodiazepine for anxiety has been self-medicating with over-the-counter antacids for recurring indigestion. Which statement will the nurse make to initially assess the patient? "Do you believe your antianxiety medicine has been working as effectively?" "Could the indigestion be related to your anxiety issues?" "When did the indigestion first present as a problem?" "How many doses of antacids do you usually take each day?"

How many doses of antacids do you usually take each day?"

The patient is experiencing panic, +4 anxiety. The staff on the unit will prepare to implement which plan of care? Closely monitor the patient every 30 minutes for safety in the therapeutic environment Guide and control the patient, and administer a medication as prescribed Arrange for staff to provide close observation for the patient while in the milieu Employ therapeutic communication skills to de-escalate the patient

Guide and control the patient, and administer a medication as prescribed

What factors determine when seclusion of an aggressive patient is terminated? The patient's expressed wishes and assurances Nursing judgment and facility protocols Staff consensus and patient behavior Patient's ability to self-manage behavior and assured milieu safety

Nursing judgment and facility protocols

A patient prescribed a tricyclic antidepressant (TCA) for chronic depression is recovering from a myocardial infarction. Which intervention will the nurse anticipate as a result of the patient's medical condition? Preparing to wean the patient off of the prescribed TCA medication Increasing the dose of the patient's prescribed TCA medication Adding an monoamine oxidase inhibitors (MAOIs) to the patient's medication regime Discontinuing the patient from all antidepressant medications temporarily

Preparing to wean the patient off of the prescribed TCA medication

An individual has experienced the death of a loved one after many years of illness. This individual says, "I am feeling okay ... he will be missed ... I remember the good experiences we had together and the challenges too." What intervention? Continue to offer emotional support. Provide a referral to an outpatient therapist. Sympathetically state "Everything will be okay." Offer to secure a prescription of an antianxiety medication.

Provide a referral to an outpatient therapist.

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the patient is experiencing acute mania? Provide nutrient-rich finger foods so the patient can eat while walking and talking. Offer only liquids that are rich in calories to avoid choking. Make food readily available knowing the client will eat when hungry. Insist that the patient join the other patients on the unit during mealtimes.

Provide nutrient-rich finger foods so the patient can eat while walking and talking.

What initial intervention should be implemented by the nurse when managing a manic patient whose behavior is disrupting a group therapy session? Setting behavioral limits for the patient that are appropriate and well defined Remaining involved with the patient while demonstrating a calm demeanor Communicating with the patient using brief, simple statements Removing the patient from the group to de-escalate the situation

Remaining involved with the patient while demonstrating a calm demeanor

he patient refuses lithium for acute mania but is agreeable to another medication. The nurse will expect the prescriber to respond with what intervention? Reinforcing that lithium is the only reasonable choice Prescribing a selective serotonin reuptake inhibitor (SSRI). Substituting the lithium with an anticonvulsant medication. Offering to prescribe a monoamine oxidase inhibitor (MAOI).

Substituting the lithium with an anticonvulsant medication.

Which older adult client is at greatest risk for later life depression and resulting suicidal thoughts? The client who has a license to carry a concealed handgun. The client who has adjustly poorly to recent retirement. The client experiencing signs of short-term memory loss. The client who recently lost a sibling and an adult child.

The client who recently lost a sibling and an adult child

A patient with a history of aggressive behavior begins pacing while talking on the telephone. The RN suspects that the patient is in the triggering phases of the assault cycle and implements which intervention? Continues to observe the patient and note additional behavioral changes. Alerts the other staff members that the patient is likely to act out. Using a calm voice, asks the patient to end the conversation immediately. Asks the patient to stop pacing or hang up the telephone.

Using a calm voice, asks the patient to end the conversation immediately.

The caregiver for an older adult diagnosed with a chronic mental illness has implemented the following interventions to help minimize the individual's tendency to become both physically and verbally aggressive. Which intervention will the nurse recognize as being ineffective? Minimizing the noise level in the individual's home Redirecting the individual's attention when the aggression first begins Utilizing the television as the individual's major source of entertainment Diverting the individual's initial anger by offering his or her favorite food

Utilizing the television as the individual's major source of entertainment

What is the nurse's best response when asked by a patient who will begin lithium therapy, "When can I expect to see improvement in my symptoms?" "The response is very individualized and dependent on the severity of the symptoms." "I can see you are anxious; let's talk about what's causing you all the worry." "We generally see symptom improvement in 7 to 10 days after beginning treatment." "Lithium is excellent at managing symptoms like yours; try to be patient."

We generally see symptom improvement in 7 to 10 days after beginning treatment."

A client has been extremely nervous ever since a person died as a result of the client's drunk driving. When assessing for the diagnosis of adjustment disorder, within what timeframe should the nurse expect the client to exhibit these symptoms? A. To meet the DSM-IV criteria for adjustment disorder, the client should exhibit symptoms within 1 year of the accident. B. To meet the DSM-IV criteria for adjustment disorder, the client should exhibit symptoms within 3 months of the accident. C. To meet the DSM-IV criteria for adjustment disorder, the client should exhibit symptoms within 6 months of the accident. D. To meet the DSM-IV criteria for adjustment disorder, the client should exhibit symptoms within 9 months of the accident.

b