Mental Health Final

Client presents flat affect increase risk of developing MDD

- Substance abuse - Mood disorder in a relative - Divorce - (NOT males- increased risk of suicide in males, depression in females)

Client has been diagnosed with MDD. Increase risk of self harm starts...?

2 weeks after starting medical regiment

A nurse is caring for four clients in the 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 nurses in assisted living facility is holding an inservice for the nursing assistant. the nurse reviews the cognitive deteriations associated with dementia. assistant correctly understands during a postest

A client may not recognize family member

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

Anergia and Anhedonia

Accommodating psychomotor retardation (NOT ruminations)

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 effects?

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

Pt says to nurse "my life doesn't have any happiness anymore.

Anhedonia

A client is admitted for MDD, the client has stated that nothing seems to be pleasurable anymore

Anhedonia, worthlessness, inability to focus

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

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

A nurse is planning discharge teaching for client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdiscplinary 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 med-surg unit is assessing a client who sustained injuries 12 hours 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 expereincing alcohol withdrawal?

Blood pressure 154/96 (hyptertension, tachycardia, fever greater than 101.)

Client with mania is hypersexual removing clothing.

Bring client to room to put clothes on

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

Priority intervention for pt diagnosed with MDD feeling symptoms of worthlessness.

Careful unobtrusive observation (for nonsuicidal)

A nurse is assessing a client who is experiencing occational feeling of sadness bc of a recent death of a beloved pet.

Client behaviors show no functional impairment and no mental illness

Which outcome would be appropriate to determine early favorable response to antidepressant needed.

Client will establish a balance of rest, sleep and activity

Nurse is planning care for a client with major depression. What is an appropriate expected outcome?

Client will independently carry out ADL's

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?

Client with COPD

Client is nearly admitted to an in pat psych unit. Which of the following is most critical to asses when assessing for suicide?

Clients history of suicide attempts

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 involunarily maintain the right to give informed consent for procedures

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 client has a lithium level of 1.2 mEq/L. Which of the following interventions by the nurse is indicated? a) Call the physician for an increase in dosage. b) Do not give the next dose, and call the physician. c) Increase fluid intake for the next week. d) No intervention is necessary at this time.

D

A client with BP is admitted talking loudly, waking back and forth & rapidly and exhibits short attention span.

Decrease stimuli

SSRI fluoxetine side effects?

Decreased sexual dysfunction

The final will have questions about grief & Kubler Ross:

Denial-anger-bargaining-depression-acceptance

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

Easily distracted

Which of the following is the most important skill a nurse must bring to the therapeutic nurse-client relationship?

Empathy

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 fo isolation

Pt diagnosed with MDD began taking epscitalopram. Pt states meds are not working, intervention?

Explain lag time before antidepressants take effect

Inappropriately dressed client has not slept for 3 days and has been making excessive long distant phone calls, nurse focuses on

Food, liquid and rest

Which statement about the tricyclic group antidepressant med is accurate?

Full therapeutic potential may not be reached until 4 weeks

Anorexia and manic who will not eat...

Give milk (has the most protein, carbs and fat)

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 posessions

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 included to reduce anxiety among the group members.

Guided imagery

Nurse must by aware of the importance of boundaries not only for the client but also for the nurse. Which of the following occurrences is considered a breach of boundaries

Having a lengthy social conversation with patient

Paroxetine overdose symptoms:

Hyperactivity, abdominal pain, GI issues, restlessness, vitals

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.

Nursing instructor is conducting a preconference with a group of nursing students on a psych unit. Which statement made by a student reflects the greatest barrier?

I think suicide is wrong and selfish

Family has a history of conflicting relationships among the members. Which family member comment best reflect a mentally healthy perspective?

I will make some changes in my behavior for the good of this client

A nurse is providing teaching to the partner of a client who is in a rehabilitiation 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 teachihng 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 and 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 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 compotent of a safety plan?

Identify signs of escalation of violence

A nurse is updating the plan of care for a client who has bullimia 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 client has been making sexual comments when communicating with the nurse, the nurse wants to spend some time when talking to a client while respecting clients rights to privacy, which setting would be most appropriate for the nurse to talk to the client?

In a quiet room in a corner of the day room. At least 4 ft away from others. • You'll want to be at arm's reach when on suicide precautions.

Which of the following is the true regarding mental health and mental illness

In most cases mental health is a state of emotional, psychological and social wellness evidence by satisfying interpersonal relationships - Effect behavior in coping, positive self-concept and emotional support

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 student nurse attends a self help group as part of a class assignment while there a student recognizes that a family friend upon returning home. The student talks about the friends attendance with the family. The students actions can be described as

Inappropriate, most self help groups have a rule of confidentiality.

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

Increased creatine phosphokinase

Pt diagnosed with MDD begins SSRI antidepressant therapy, nurse should teach family

Inform pt about increased suicidal thoughts

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

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

A group is in the working phase, one member says, that is the stupidest thing I have ever heard. Everyone whines and tells everyone else what to do, this group is a total waste of my time. Which comment by the group leader would be the most therapeutic?

It must be so hard to be so angry", turn to another group member, "you were also angry about this at first but now you're not. What has helped you"

A leader begins a discussion at the first meeting of a new group; which comment should be included?

Its important for everyone to arrive on time for our group - When someone shares something in the group it is important to keep it confidential

Pt diagnosed with SAD, month is most acute symptom

January

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 the nurse identify as an indication that the child is experiencing PTSD?

Lack of interest in an upcoming holiday

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 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 talk about what is upsetting you

Which nursing interventions will be implanted for a pt who is actively suicidal.

Maintain arms length, one-on-one direct observation at all times

Pt diagnosed wit MDD does not interact with others when addressed, responds in monosyllables. Nonjudgment support intervention?

Make observations

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

Client with bipolar disorder takes lithium 300mg/day. Nurse is indicating dose is appropriate when...

Minimal mood swings

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

Monitor the client's cardiac rhythm during the procedure

Nurse is caring for a client who plans to commit suicide by hanging. Client states I plan on using shower curtain when no one is around.

More specific plan is the more likely he/she will follow through

mod alheimers is living with daughter. What statement indicates a need for intervention?

Mother won't let anyone else do anything for her

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.

Nurse observe pt looking sad, client turns away.

Move to another chair and sit quietly

A client with bipolar disorder Lithium serum blood level is 2.0. Symptoms?

Nausea, diarrhea, confusion

An experience nurse says to a new grad " when you've practice as long as ive had, you automatically know how to take care of pt's experiencing psychosis. Which factor should new grad consider when analyzing this comment?

New research findings should be integrated continuously into a nurse practice to provide most effective care. - The experienced nurse may have lost sight of pts individuality which may compromise the integrity of practice

A nurse is planning care for a client who has made repeated physical threats towards 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.

Nonmaleficence

A nurse is preparing to discharge to home an older adulat 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

The nurse is sitting with a client who is crying. Nurse places one hand on client's shoulder for what purpose?

Offer comfort and support to the client. • Do not use touch with PTSD or Schizophrenia. Rule of thumb, ask first

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 inidication of a boundary issue?

Older children who are responsible for their younger siblings

Immediately after ECT, Which position should nurse place client

On side to prevent aspiration

A nurse discovers a clients a clients suicide note that details time, place and means to commit suicide. What should be the priority nursing intervention and rationale for action?

One to one precautions

Client is diagnosed with MDD hears voices commanding self harm, Which should be the nurses priority intervention at this time?

One-to-one observation

Individual Therapy is recommended for

People generally seek this kind of therapy based on their desire to understand themselves and their behavior, to make personal changes, to improve interpersonal relationships, or to get relief from emotional pain or unhappiness.

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 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

Phenylephrine

A client who manic states " what time is it?" I have to see a doc, what time is breakfast? I gotta go see a doc here first! Can I get my cereal from the kitchen?

Please slow down, I'm not sure what you need first

Client diagnosed with severe depression during assessment, nurse is aware of what of the following?

Primary consideration of taking antidepressants is suicide

A group has tewo more sessions before it ends, one member previously vocal and has shown progress has grown silent.

Pt is having trouble dealing with feelings of termination

Pt experiencing psychomotor agitation associated with MDD.

Pt paces aimlessly around room

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 prioirity?

Reduce environmental stimuli

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

Renew the prescription for the client every 4 hours

Which techniques will best communicate to a pt that a nurse is interested in listening?

Restating a feeling or thought of a pt has expressed

Client with schizophrenia has been noncompliant with medications. The client requires frequent admissions at a psychiatric unit for an acute psychotic episode. What is the process called?

Revolving door

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

Rhinorrhea (yawn, sneeze, abdominal pain, flu like symptoms)

What is the priority nursing diagnosis for a depressed client exhibiting signs of acute mania that include agitation, insomnia, increased physical training and anorexia.

Risk for injury

A client whos manic threatens others on the unit, which would be the initial nursing action response to behavior?

Setting limits on aggression and intimidating behavior

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

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

The nurse is sitting down with a client to begin a conversation, which of the following position should the nurse take to convey acceptance of the client.

Sitting upright, facing the client with both feet on floor.

A pt became depressed after kids moved out 4 months ago, pt states "no one cares about me, im not worth anything, which response will be most helpful?

Sitting with them for 10 min (*do not fixate on time frame, spending time with them is what makes this correct)

MDD resulted after employment terminated. Pt states "I'm not worth the time"

Situational low self esteem

Which documentation for a pt diagnosed with MDD indicates treatment plan was effective?

Sleep 6hrs uninterrupted, sang with activity group, anticipates seeing grandkid

Adult diagnosed with MDD was treated with meds and CBT. PT now recognizes how passivity contributed to depression, which interventions should nurse suggest?

Social skills training

Rational for nurse to perform a fall physical health assessment on a client admitted for MDD

Somatic symptoms that mask real medical problems

Sitting upright, facing the client with both feet on floor.

Spending adequate time with a client who is verbally abusive

Client asked the nurse why he goes to therapy and cant just take prescribed meds. Which would be the most therapeutic intervention?

Stating the med helps you to get better, but the therapy helps you achieve lasting behavior change

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 hour after mealtimes

A nurse in a mental health clinic is caring for a client who has PTSD after returing 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 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.

Pt who has been taking ssri's state that he felt awful when he started taking OTC St John's wort herbal product at home. The nurse suspects serotonin syndrome. What are the symptoms?

Sweating, tremors, agitation

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

Tachycardia

a client with dementia starting pharmacotherapy to slow down progression of cognitive decline. The client has a history of taking alcohol over the past 45 years. Which med is least suitable for the clients? Donepezil Memantine Tacline Rivastigmine

Tacline (contrindicated in liver issues)

A concerned family member of a bipolar patient

Taking unnecessary risks

A pt diagnosed with MDD receives 6 ECT sessions and aggressive doses of antidepressive meds. PT owna a small business and was counselled on to not take major decisions for a month. Rationale?

Temporary memory impairment and confusion may occur

Nursing instructor is teaching about the DSM-V about disruptive mood dysregulation disorder?

Temporary outburst must be present - Symptoms should be verbal ranges or physical aggression towards people or property

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

Which of the following considerations should have the most influence the nurse choice in tx for the client?

The clients feelings and perceptions about his/her situation

A newly admitted homeless client diagnosed with schizophrenia states I have been living in a cardboard box for 2 weeks. Why did the government let me down? Which is an appropriate response?

The discharge from the state hospital based on firm principles however the resources were not available to make the transition a success.

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

Tooth erosioin

A client at the mental health clinic tells the case manager "I don't think about living another day" nurses response

Tx team is composed of many specialists who are working with you. Sharing this info with the team is critical to your care.

The client reports a history of anxiety, diagnosed with Alzheimer's disease 2 months ago. The client's partner died 6 months ago. Reports decreased appetite, low energy levels, and insomnia for several weeks, some memory loss

Use a screening tool to evaluate the client for depression

Diagnosis of MDD, an advanced practice nurse will address the negative thought process patterns

Using CBT

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

WBC count 2,500 (agranulocytosis below 3,000)

The wife of a client with bipolar disorder calls nurse about husband spending habits.

Wife needs support in setting boundaries

Client is depressed and says nothing goes right in my life or goes my way. Nurses response?

You're feeling sad right now, it's a hard time

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 are using laxatives because you are afraid of gaining weight

The client grieving the recent loss of her husband asked if she is becoming mentally ill because she is so sad. The nurse best response would be

Your not mentally ill, this is an expected reaction to loss you have experienced.

The basic assumption of freuds psychoanalytic theory is that?

all human behavior can be caused and explained

Attending self-help group is good for

anyone dealing with grief or loss of friends/family

Which of the interventions will the nurse recommend for the famiy, friends of client who has committed suicide?

attending self help group

Which of the following statements is true of the component of a therapeutic relationship term acceptance?

avoiding judgements of the person no matter what the behavior is

How would you define depression as it relates to anger?

depression is "anger turned inward

Risks for suicide

divorce, single, male, depression, substance abuse

An employee uses a defense mechanism of displacement when the boss openly disagrees to suggestions. What behavior would be expected from the employee?

employee criticizes coworker.

Which of the following goals of therapeutic communication would the nurse strive to attain first?

establishing nurse client communication

A pt detoxification unit asks what good will it do to go to aa and talk to people with the same problems? Best response

explain that self help groups such as aa provide opportunities for people with common problems to share their experiences with alcoholism recovery.

Which of the following statement is true of empathy?

gather info from client - place self into another for a moment

your taking care a client with alzheimers, which abnormality is found to be associated with LATE ONSET alzheimers

genetic component of chromosome 21,14,19

Nurse giving tyramine restricted client, which menu options would be approved?

ground beef, mash, greenbeans, apple pie

What do you do if you say the wrong thing to a client?

it didn't come out right, what I meant was...

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 behaviors.

When attempting to provide healthcare services to the homeless, what would be a realistic concern for a nurse

most homeless relocate frequently

A client has asked about a complmentary and alternative therapy, which of the following are complementary and alternative therapies?

music/art, aromatherapy, massage

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

nform the client that this admission is confidential

By talking with a pt diagnosed with MDD, a nurse notices the pt is unable to maintain eye contact, Pt chin lowers to the chest, looks at the floor; which aspect of communication has the nurse assessed?

nonverbal

a client with dementia gets angry and begins to yell at the nurse during meal time. the nurse leaves the client for 5-10 min and then returns. What is the rationale

nurse gave client a chance to calm down

Client is supposed to be ambulating ad lib, instead he refuses to get out of bed, asks for bed bath and demands of the nurses. He also yells at them calling them lazy and incompetent. Defense mech is and example of

projection

Which tasks should a nurse place priority during the working phase of relationship development?

promoting the clients insight and perception of reality

A client has just been told she has cervical cancer. She states "Its just an infection, it will clear up

pt is using denial

New grad nurse has accepted a staff position at an inpatient mental health facility. The graduate nurse can expect to be responsible for basic level functions including

using effective communication skills

nurse came for a client with delirium who is experiencing illusions. what environmental conditions...

well lit room , no noise , no shadows

Devastated by a divorce from an abusive husband. A wife completes grief counseling. Which statement by the wife would indicate the patient in acceptance of stage grief?

yes, it was a difficult experience but I think I've learned from the experience.