Mental health

A nurse is caring for a client who had substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, " the voices won't leave me alone!" Which of the following statements should the nurse make?(select all that apply)

-"when did you start hearing these things?"* - "the voices aren't real, or else we would both hear them." -"it must be scary to hear voices."* -" are the voices telling you to hurt yourself?"* -"why are the voices talking only to you?"

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation?(select all that apply)

-Client ate most of their breakfast -client was offered 8oz of water every hour* -client shouted obscenities at assistive personal* - client received chlorpromazine 15 mg by mouth at 1000* -client acted out after lunch

A nurse is completing admission data collection for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms?(select all that apply)

-auditory hallucinations* -lack of motivation -use of clang associations* -delusion of persecution* -constantly waving arms* -flat affect

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?

A. "I am a superhero and am immortal." B. " I am no one, and every is me." C. "I feel monsters pinching me all over." D. " I know that you are stealing my thoughts." B

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?

A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago. C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod. D. A client who has bipolar disorder and paces around the room while talking to themself. C

A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider?

A. Blurred vision B. Urinary retention C. Muscle flaccidity D. Elevated temperature D

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, " kill your doctor". Which of the following actions should the nurse take first?

A. Encourage the client to participate in group therapy on the unit. B. Initiate one-to-one observation of the client. C. Focus the client on reality. D. Notify the provider of the clients statement. B

A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect?

A. I pick my face when I'm nervous B. I have bald patches from pulling my hair C. I inspect my body in the mirror several times a day D. I am unable to part with any of my belongings A

A nurse is reinforcing teaching with a client who has a new prescription for varenicline for smoking cessation. Which of the following statements by the client indicates an understanding of the teaching?

A. If I fail to stop smoking after 12 weeks, I will have to try another product B. I will take the medication for 7 days before I try to stop smoking C. This medication will cause me to lose weight as I stop smoking D. I will take this medication after eating meals D

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short staffed, and the client frequently fights with other clients. The nurses actions is an example of which of the following torts?

A. Invasion of privacy B. False imprisonment C. Assault D. Battery B

A client tells a nurse, " don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me." Which of the following actions should the nurse take first?

A. Keep the clients communication confidential, but talk to the client daily , using therapeutic communication to convince them to hiding the knife. B. Keep the clients communication confidential, but watch the client and their roommate closely. C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others. D. Report the incident to the health care team, but do not inform the client of the intention to do so. C

A nurse is caring for a client who has been taking fluoxetine for anxiety. Which following adverse effect of this medication should the nurse report to the provider immediately?

A. Mydriasis B. Hallucinations C. Arthralgia D. sexual dysfunction B

A nurse heads a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the collections should the nurse take first?

A. Notify the nurse manager B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report. B

A nurse is contributing to the plan of care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following goals should the nurse identify as the priority?

A. Practicing problem - solving skills B. Understanding the medication regimen C. Identifying indications of relapse D. Maintaining adequate hydration D

A nurse is contributing to the plan of care for a client with bipolar disorder who has a cure mania. Which of the following interventions should the nurse recommend including in the plan?

A. Provide the client with low calorie,low fat diet B. Encourage the client to have frequent rest periods C. Escort the client to daily group therapy D. Limit the clients intake of caffeinated beverages to 12oz per day B

A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurses questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, " are you seeing something in the ceiling?" C. Tell the client," you seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without commenting on the clients behavior. B