Mental Health Exam 2 SAUNDERS Practice Questions

the nurse is planning care fo a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention would the nurse include in the plan of care? a.) one to-one suicide precautions b.) suicide precautions with 30 minute checks c.) checking the whereabouts of the client every 15 minutes d.) asking the client to report suicidal thoughts immediately

a.) one to-one suicide precautions

a client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L) the nurse plans care based on which representation of this level? a.) toxic b.) normal c.) slightly above normal d.) excessively below normal

a.) toxic

a hospitalized client has begun taking bupropion (NDRI) as an antidepressant agent. the nurse determines which is an adverse effect, indicating that the client is taking an excessive amount of the med. a.) constipation b.) seizure activity c.) increased weight d.) dizziness when getting upright

b.) seizure activity

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which actions would the nurse take to plan appropriate nursing care? a.) ask the client why they started taking illegal drugs b.) ask the client about the amount of drug use and its effect c.) ask the client how long they thought they could take drugs without someone finding out d.) not ask any questions for fear that the client is in denial and will throw the nurse out of the home

a.) ask the client why they started taking illegal drugs

the nurse notes that a client with schizophrenia who is receiving an antipsychotic med is moving his mouth, protruding the tongue, and grimacing while watching TV the nurse determines the client is experiencing which med complication. a.) parkinsonism b.) tardive dysnkinesia c.) hypertensive crisis d.) neuroleptic malignant syndrome

b.) tardive dysnkinesia

the nurse determines that the spouse of an alcoholic client is benefiting from attending AL-anon group if the nurse hears the spouse make which statement? a.) I will no longer feel that I deserve the beatings my partner inflicts on me b.) my attendance at the meetings has helped me to see that I provoke my partner's violence c.) I enjoy attending the meetings because they get me out of the house and away from my partner d.) I can tolerate my partner's destructive behaviors now that I know they are common among alcoholics

a.) I will no longer feel that I deserve the beatings my partner inflicts on me

the nurse in the ED is caring for a young victim of sexual assault. The client's physical assessment is complete and physical evidence has been collected. The nurse notes that the client is withdrawn distracted tremulous and bewildered at times. How would the nurse interpret these behaviors? a.) signs of depression b.) reactions to a devastating event c.) evidence that the client is a high suicide risk d.) indicative of the need for hospital admission

b.) reactions to a devastating event

the nurse is teaching a client who is being started on imipramine about the medication. The nurse would inform the client to expect max desired effects at which time period following initiation of the med? a.) in 2 months b.) 2-3 weeks c.) during the first week d.) during the 6th week of administration

b.) 2-3 weeks

the nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. which findings would alert the nurse to the potential for alcohol withdrawal delirium? a.) hypotension, ataxia, hunger b.) stupor, lethargy, muscular rigiity c.) hypotension, coarse hand tremors, lethargy d.) hypertension, changes in level of consciousness, hallucinations

d.) hypertension, changes in level of consciousness, hallucinations

a client with schizophrenia has been started on medication therapy with clozapine. the nurse would assess the results of which lab study to monitor for adverse effects from this med? a.) platelet count b.) blood glucose level c.) liver function studies d.) white blood cell count

d.) white blood cell count

the nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction would the nurse provide to the client? a.) get adequate sunlight b.) continue driving as usual c.) avoid foods rich in potassium d.) get up slowly when changing positions

d.) get up slowly when changing positions

a client's med sheet contains a prescription for sertraline. to ensure the safe administration of medication, how would the nurse administer the dose? a.) on an empty stomach b.) at the same time each evening c.) evenly spaced around the clock d.) as needed when the client complains of depression

b.) at the same time each evening

a hospitalized client with a history of alcohol use disorder tells the nurse "I am leaving now. I must go. I do not want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What actions would the nurse take? a.) call the nursing supervisor b.) call security to block all exit areas c.) restrain the client until the primary care provider can be reached d.) tell the client that the client cannot return to this hospital again if the client leaves now

a.) call the nursing supervisor

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment finding would the nurse expect to note? select all that apply. a.) dental decay b.) moist, oily skin c.) loss of tooth enamel d.) electrolyte imbalances e.) body weight well below ideal range

a.) dental decay c.) loss of tooth enamel d.) electrolyte imbalances

the ED nurse is caring for an adult client who is a victim of family violence, which priority nursing information would be included in the discharge instructions? a.) information regarding shelters b.) instructions regarding calling the police c.) instructions regarding self-defense classes d.) explanation of the importance of leaving the violent situation

a.) information regarding shelters

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply a.) monitor vitals b.) provide a safe environment c.) address hallucinations therapeutically d.) provide stimulation in the environment e.) provide reality orientation as appropriate f.) maintain NPO (nothing by mouth status)

a.) monitor vitals b.) provide a safe environment c.) address hallucinations therapeutically e.) provide reality orientation as appropriate

the nurse is performing a follow-up teaching session with a client discharged 1 month ago, the client is taking fluoxetine which information would be important for the nurse to obtain during this client visit regarding the specific side effects of this med? a.) renal dysfunctions b.) GI dysfunctions c.) dry mouth d.) excessive sweating

b.) GI dysfunctions

a client is admitted with a 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 PTSD. select all that apply a.) I'm afraid of spiders b.) I keep reliving the robbery c.) I see that face everywhere I go d.) I don't want anything to eat now e.) I might have died over a few dollars in my pocket f.) I have to wash my hands over and over again many times

b.) I keep reliving the robbery c.) I see that face everywhere I go e.) I might have died over a few dollars in my pocket

a client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? a.) a client with pneumonia b.) a client undergoing diagnostic tests c.) a client who thrives on managing others d.) a client who could benefit from the client's assistance at meal time

b.) a client undergoing diagnostic tests

the nurse has been closely observing a client who has been displaying aggressive behaviors. the nurse observes that the behavior displayed by the client is escalating. which nursing intervention is most helpful to his client at this time? select all that apply a.) initiate confinement measures b.) acknowledge the client's behavior c.) assist the client to an area that is quiet d.) maintain a safe distance from the client e.) allow the client to take control of the situation

b.) acknowledge the client's behavior c.) assist the client to an area that is quiet d.) maintain a safe distance from the client

the police arrive at the ED with a client who has lacerated both wrists. which is the initial nursing action? a.) administer anti-anxiety agent b.) assess and treat the wound sites c.) secure and record a detailed history d.) encourage and assist the client to ventilate feelings

b.) assess and treat the wound sites

a client with anorexia nervosa is a member of a predischarge support group the client verbalizes interest in buying new clothes but expresses that money is limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior? a.) normal behavior b.) evidence of the client's disturbed body image c.) regression as the client is moving toward the community d.) indicative of the client's ambivalence about hospital discharge

b.) evidence of the client's disturbed body image

the nurse is describing the medication SEs and adverse effects to a client who is taking amitriptyline (TCA) which information would the nurse incorporate in the discussion? a.) consume a low-fiber diet b.) increase fluids and bulk in the diet c.) reset if the heart begins to beat rapidly d.) walk if you have difficulty urinating because this is a normal side effect

b.) increase fluids and bulk in the diet

a client who has been taking buspirone for one month returns to the clinic for a follow-up assessment, the nurse determines that the med is effective if the absence of which manifestation has occurred a.) paranoid thought process b.) rapid heartbeat or anxiety c.) alcohol withdrawal symptoms d.) thought broadcasting or delusions

b.) rapid heartbeat or anxiety

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? a.) the adolescent runs out of the therapy group, swearing at the group leader b.) the adolescent gives away a DVD and a cherished autographed picture of a performer c.) the adolescent becomes angry while speaking on the phone and slams down the receiver d.) the adolescent gets angry with a roommate who borrowed the client's clothes without asking

b.) the adolescent gives away a DVD and a cherished autographed picture of a performer

the nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? a.) witnessing a murder b.) the death of a loved one c.) a fire that destroyed the client's home d.) a recent rape episode experience by the client

b.) the death of a loved one

the spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation" which is the most helpful response by the nurse? a.) why don't you tell your spouse about this? b.) what do you find difficult about this situation? c.) this is not the best time to make that decision d.) I agree with you you should get out of this situation

b.) what do you find difficult about this situation?

a client is admitted to the mental health unit after attempted suicide by hanging, the nurse can best ensure the client's safety by which action? a.) requesting that a peer remains with the client at all times b.) removing the client's clothing and placing the client in a hospital gown c.) assigning the client a staff member who will remain with the client at all times d.) admitting the client to a seclusion room where all potentially dangerous articles are removed

c.) assigning the client a staff member who will remain with the client at all times

a client receiving tricyclic antidepressants arrives at the mental health clinic which observation would indicate that the client is following the medication plan correctly a.) client reports not going to work for the past week b.) client complains of not being able to do anything anymore c.) client arrives at the clinic neat and appropriate appearance d.) client reports sleeping 12 hours per night and 3-4 hours during the day

c.) client arrives at the clinic neat and appropriate appearance

a hospitalized client is started on an MAOI for the treatment of depression the nurse would instruct the client on which food is acceptable to consume while taking this med select all that apply a.) figs b.) yogurt c.) crackers d.) aged cheese e.) tossed salad f.) oatmeal raisin cookies

c.) crackers e.) tossed salad

a moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. the client says to the nurse "I'm finally cured" based on the client's statement, which intervention would the nurse include in the plan? a.) suggesting a reduction of medication b.) allowing increased in-room activities c.) increasing the level of suicide precautions d.) allowing the client off-unit privileges as needed

c.) increasing the level of suicide precautions

a victim of sexual assault is being seen in the crisis center. The client states, "I still feel as though the rape just happened yesterday" even though it has been a few months since the incident. which is the most appropriate nursing response? a.) you need to try to be realistic the rape did not just occur b.) it will take some time to get over these feelings about your rape c.) tell me more about the incident that causes you to feel as if the rape just occurred d.) what do you think think you can do to alleviate some of your fears about being raped again?

c.) tell me more about the incident that causes you to feel as if the rape just occurred

the nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? a.) with whom do you live b.) who is available to help you c.) what leads you to seek help now d.) what do you usually do to feel better

c.) what leads you to seek help now

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? a.) you need to stop that behavior now b.) you will need to be placed in seclusion c.) you seem restless; tell me what is happening d.) you will need to be restrained if you do not change your behavior

c.) you seem restless; tell me what is happening

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse would consider which factor? a.) a crisis state indicated that the client has a mental illness b.) a crisis state indicated that the client has an emotional illness c.) presenting symptoms in a crisis situation are similar for all clients experiencing a crisis d.) a client's response to a crisis is individualized, and what constitutes a crisis for one client may not constitute a crisis for another client

d.) a client's response to a crisis is individualized, and what constitutes a crisis for one client may not constitute a crisis for another client

a client is scheduled for discharge and will be taking phenobarbital for an extended period. the nurse would place the highest priority on teaching the client which points that directly related to client safety. a.) take the medication only with meals b.) take the medication at the same time each day c.) use a dose container to help prevent missed doses d.) avoid drinking alcohol while taking this med

d.) avoid drinking alcohol while taking this med

a client gives the home health nurse a bottle of clomipramine. the nurse notes that the medication has not been taken by the client in 2 months. which behavior observed in the client would validate noncompliance with this med? a.) complaints of insomnia b.) complaints of hunger and fatigue c.) a pulse rate of less than 60 bpm d.) frequent hand washing with hot soapy water

d.) frequent hand washing with hot soapy water

the nurse is caring for a client who was admitted to the mental health unit recently for anorexia nervosa. the nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? a.) allow the client to complete the exercise program b.) interrupt the client and weigh the client immediately c.) tell the client that exercising rigorously is not allowed d.) interrupt the client and offer to take the client for a walk

d.) interrupt the client and offer to take the client for a walk

a depressed client on an inpatient unit says to the nurse, "my family would be better off without me" which is the nurse's best response? a.) have you talked to your family about this? b.) everyone feels this way when they are depressed c.) you will feel better once your medication begins to work d.) you sound very upset, are you thinking of hurting yourself?

d.) you sound very upset, are you thinking of hurting yourself?