MH Practice B
a nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? A. increased creatine phosphokinase (CPK) B. increased low-density lipoproteins (LDL) C. decreased fasting blood glucose D. decreased aspartate aminotransferase (AST)
A. increased creatine phosphokinase (CPK) An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy.
a nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? A. inform the client that this admission is confidential B. introduce the client to other clients in the day room C. assist the client in facilitating behavioral change D. determine coping strategies that the client has used in the past
A. inform the client that this admission is confidential According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship.
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? A. "I will spend extra time at work to keep from feeling depressed." B. "I will talk about my feelings with a close friend" C. "I will be able to learn how to prevent my partner's attack" D. "I will use mediation instead of taking my antidepressant"
B. "I will talk about my feelings with a close friend" Discussing feelings, such as fear and depression, with a support person is an effective coping strategy and can provide the client with emotional support and other resources.
a nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? A. "you probably want to hold your baby" B. "I'll stay with you just in case you want to talk" C. "I know how you must be feeling" D. "It hurts now, but things will get better soon"
B. "I'll stay with you just in case you want to talk" This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings.
a nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis? A. "She works so hard at ballet. Will she still be able to perform?" B. "She won't let me take the trash from her room. I'm concerned about what she has in there." C. "She told me she was tired, so I did her chores for her today." D. "She is happier with her appearance now that she's lost some weight."
B. "She won't let me take the trash from her room. I'm concerned about what she has in there." The client might be binge eating and attempting to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent's statement indicates awareness of the client's behavior.
a nurse is caring for a client who is an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? A. develop a code word that means "time to go" B. identify signs of escalation of violence C. have a predetermined place to go in the event of violence D. keep a hidden packed bag of necessities
B. identify signs of escalation of violence It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the first component of the safety plan because it increases awareness of when danger is imminent and it is time to leave.
a nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan A. include a liquid supplement with meals B. identify the client's trigger foods C. allow the client at least 1 hr for each meal D. weight the client at bedtime each day
B. identify the client's trigger foods The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.
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? A. the program will help the client accept responsibility for the disorder B. the client should obtain a sponsor before discharge for an increased chance of recovery C. the client will need to identify individuals who has contributed to the disorder D. the program will need a prescription from the client's provider prior to attendence
B. the client should obtain a sponsor before discharge for an increased chance of recovery The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program.
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? A. "client can't refuse to take medications if they are admitted involuntarily" B. "you can notify a client's family if they are admitted involuntary" C. "clients who are admitted involuntarily maintain the right to give informed consent for procedures" D. "you can remove a client's privileges if they are admitted involuntarily and refuse to attend therapy sessions."
C. "clients who are admitted involuntarily maintain the right to give informed consent for procedures" Clients who are admitted involuntarily maintain the right to give informed consent for treatment. They also have the right to give informed consent for procedures.
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? A. repeatedly talks about the traumatic incident B. sleeps excessively C. experiences feelings of isolation D. uses repetitive speech
C. experiences feelings of isolation The nurse should expect clients who have PTSD to feel estranged and detached from others.
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? A. offer the client various choices for meal selection B. assign different nursing personnel for each shift C. permit the client to perform daily rituals to decrease anxiety D. maintain an environment that has low lighting.
C. permit the client to perform daily rituals to decrease anxiety The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.
a nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment. Which of the following is the priority action for the nurse to take? A. assist the client to identify personal areas of strength B. encourage the client to talk about experiences during the deployment C. stay with the client when flashbacks occur D. teach the client stress-management techniques
C. stay with the client when flashbacks occur The greatest risk to this client is injury that can occur during a flashback; therefore, the priority intervention for the nurse is to remain with the client and offer reassurance and support 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? A. encourage the parents to avoid discussing the death with their other children to protect their feelings B. recommend each parent grieve in private to avoid hindering each other's healing C. suggest forming a weekly support group for parents who have experienced the death of a child D. advise the parents to begin counseling if they are still grieving in a few months
C. suggest forming a weekly support group for parents who have experienced the death of a child Support groups are a positive resource in the process of recovery for parents following the death of a child.
a nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression A. the client is married B. the client recently received a promotion at work C. the client has COPD D. the client is a male
C. the client has COPD The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression.
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? A. blurred vision B. orthostatic hypotension C. dry mouth D. acute dystonia
D. acute dystonia The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.
a nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home? A. community mental health center B. mental health day program C. partial hospitalization program D. assertive community treatment
D. assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.
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? A. inability to communicate with others B. feelings of absence of self-worth C. lack of motivation to perform daily tasks D. command hallucinations
D. command hallucinations A client who has schizophrenia and is experiencing command hallucinations can hear voices telling them to hurt themselves or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self-directed injury or injuring others.
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 post-traumatic stress disorder (PTSD)? A. clinging behavior directed towards the teacher B. increased time spent sleeping C. intense focus on school work D. lack of interest in an upcoming holiday
D. lack of interest in an upcoming holiday The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child can also have a loss of interest or lack of participation in significant activities and events such as holidays.
a nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A. lansoprazole B. naproxen C. magnesium hydroxide D. phenylephrine
D. phenylephrine Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.
a nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority? A. encourage expression of feelings B. support the child's attendance at an assertive training group C. assist the child to perform relaxation breathing D. reduce environmental stimuli
D. reduce environmental stimuli The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.
a nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice A. allowing a client to choose which unit activities to attend B. attempting alternative therapies instead of restraints for a client who is combative C. providing a client with accurate information about their prognosis D. spending adequate time with a client who is verbally abusive
D. spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care
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)? A. discuss outpatient resources with a client who has post-traumatic stress disorder B. create a plan of care for a client who is experiencing alcohol withdrawal C. explain sleep hygiene to a client who has insomnia D. stay with a client who has anorexia nervosa for 1 hr after mealtimes
D. stay with a client who has anorexia nervosa for 1 hr after mealtimes Staying with a client who has anorexia nervosa following mealtimes is within the range of function of an AP. APs are allowed to attend to the safety of clients who are stable, and this task does not require assessment or technical skill.
Nurse's Notes 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. Graphic Results SaO2 96% on room air Respiratory rate 20/min Blood pressure 112/76 mm Hg (lying) Blood pressure 104/68 mm Hg (standing) Heart rate 68/min Temperature 36° C (96.8° F) Medication Administration Record Captopril 12.5 mg by mouth three times daily Digoxin 0.125 mg by mouth each morning Multivitamin with iron one by mouth daily Docusate sodium 50 mg by mouth each evening a nurse at a provider's office is interviewing an older adult client. Which of the following actions should the nurse plan to take?
use a screening tool to evaluate the client for depression Depression can be underdiagnosed among older adult clients. The nurse should identify several risk factors for depression from the client's data, including having Alzheimer's disease, anxiety, and the loss of a loved one. Manifestations of depression can also be nonspecific for older adult clients and can include weight loss, decreased energy levels, and difficulty sleeping.
