NCLEX Mental Health (UW)
A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following?
Loose associations
What foods are good to give a patient experiencing mania?
Nurses should provide easily carried and consumed foods high in energy and protein (eg, burgers, sandwiches, shakes) to promote adequate nutritional intake.
What are the behaviors of a codependent person?
- Codependent persons will focus all their attention on others at the expense of their own sense of self. - Codependent spouses, friends, and family members keep the client from focusing on treatment; this behavior is counterproductive to both themselves and the client.
What are strategies for behavioral management in Alzheimer's?
1) Focus on reality and verbally reinforce it 2) Focus on the client's feelings secondary to the delusions
The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include?
A list of everyday items containing hidden alcohol - the drug can last for 2 weeks after last dose
What is Wernicke encephalopathy?
Alcohol toxicity and thiamin deficiency cause Wernicke encephalopathy characterized by delirium, ataxia, and eye paralysis.
Which clinical manifestations would the nurse identify with severe anorexia nervosa?
Amenorrhea Fluid and electrolyte imbalances Presence of lanugo Weight loss of below 25% of normal weight - Severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance
What personality disorder has problems with authority figures?
Antisocial personality disorder
ECT (electroconvulsive therapy) info
ECT is used when it is unsafe to wait for medication treatment to become effective. It is also used in clients who do not respond to or cannot tolerate psychotropic medications. - General anesthesia and muscle relaxants are used
What are characteristics of schizoid personality disorder?
Exhibit social detachment and an inability to express emotion. They do not enjoy close relationships and prefer to be aloof and isolated.
The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse?
I know you are frightened, but I do not see a man in your room. - The most therapeutic response to a client experiencing hallucinations presents reality and acknowledges how the client may be feeling.
The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment?
Low self esteem and impaired social skills
What are predisposing factors of delirium?
1) Advanced age 2) Underlying neurodegenerative disease (stroke, dementia) 3) Polypharmacy 4) Coexisting medical conditions (eg, infection) 5) Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) 6) Metabolic and electrolyte disturbances 7) Impaired mobility - early ambulation prevents delirium 8) Surgery (postoperative setting) 9) Untreated pain and inadequate analgesia
A client with moderate Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor. Which of the following responses by the nurse are appropriate?
1) Redirect patient by asking for help folding napkins for tomorrow's meals 2) I can see that you are upset, but this is a safe place.
A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder?
Agoraphobia - Agoraphobia is characterized by intense anxiety about being in a situation from which there may be difficulty escaping in the event of a panic attack. A person with agoraphobia may avoid open spaces, closed spaces, riding in public or private transportation, going outside the home, bridges/tunnels, and crowds.
The new nurse is providing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene?
Be sure to take your valproic acid prior to the exam
An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?
Providing one on one supervision
The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides. Which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse?
1) Teenage parents are particularly vulnerable to abusing their children 2) Abusers often have a history of drug abuse 3) Most child abusers have low self esteem 4) Abusers often have a history of growing up in an environment of domestic violence
A nurse on the telemetry unit receives a client admitted from the emergency department with acute alcohol intoxication, confusion, and a diabetic toe ulcer. Which intervention would be the priority?
Monitor BG levels - Alcohol can cause hypoglycemia, but intoxication can make it difficult to differentiate between the effects of alcohol and hypoglycemia. Clients with acute alcohol intoxication, especially those who have diabetes mellitus, should have their blood glucose levels monitored.
A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client?
Provide continuous one on one monitoring with the patient
The nurse is caring for a dying child on a palliative unit. Which statement by the nurse is most important to make to the parents immediately following the death of their child?
Some parents like to cuddle and speak to the child. Take the time you need.
What are the legal criteria for involuntary admission to a psych unit?
The individual appears to be an imminent danger to self or others. The individual has a grave disability (ie, is unable to adequately care for basic needs [food, clothing, shelter, medical care, personal safety]) as a result of a mental illness.
A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia, and confusion. The client's breath smells of alcohol. Which prescription from the health care provider should the nurse implement first?
Thiamine IV - IV thiamine is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. Clients with alcoholism often have thiamine deficiency. - Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis).
A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies?
Desensitization to certain situations Relaxation techniques Self observation and monitoring Teaching new coping skills and techniques to reframe thinking
A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. The client has a history of physical violence. Which intervention should the nurse implement at this time to prevent the client from becoming violent?
Explain all activities of care clearly and calmly while facing the patient - Placing the client near the nurses' station may increase anxiety due to the noise and activity in that area. - The presence of security personnel does not prevent violence and may cause increased client anxiety. The nurse should consider other interventions (eg, effective communication) to prevent violence.
What are the trademarks of therapeutic communication?
The nurse should initiate conversations by: - acknowledging clients' fears - use open-ended statements to invite them to talk about death - actively listen as they verbalize their feelings. - Do not ask why questions. When discussing ethical decisions related to client care, it is important for the nurse to use open-ended questions and guiding phrases to facilitate exploration of clients'/family members' emotions, values, and beliefs regarding the topic. Nurses should avoid giving advice and influencing individuals' decisions.
More on histrionic personality disorder
The nurse should recognize the following characteristics associated with histrionic personality disorder: 1) Self-dramatizing, exaggerated or shallow emotional expression 2) Attention-seeking, needs to be the center of attention 3) Overly friendly and seductive, attempts to keep others engaged 4) Demands immediate gratification and has little tolerance for frustration
A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan?
Assign different members of staff to care for the patient each day - Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to rotate staff members assigned to care for the client.
A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client?
CBC and neutrophil count - Agranulocytosis, a serious adverse effect of clozapine, is potentially fatal. Pretreatment assessment and ongoing monitoring of WBC and absolute neutrophil counts are critical. Clients should contact the health care provider if they develop fever or sore throat, which can indicate infection due to neutropenia.
When should patients with eating disorders be monitored?
Clients should be monitored around meal times, and particularly for 1-2 hours after eating to observe for purging. - These disorders can result in hypokalemia
What are characteristics of antisocial personality disorder?
Clients with antisocial personality disorder have a pattern of disregard for and violation of the rights of others. They manipulate others for personal gain and lack empathy.
A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the best recreational activity for this child?
Connect the dots puzzle book - A child with moderate intellectual disability: Has academic skills at about the 2nd grade level and may be able to work in a sheltered workshop Performs self-care activities with some supervision Participates in simple activities May have limited speech capabilities
What are the characteristics of delirium?
Delirium has a sudden onset and involves fluctuating mental status and inattention with disorganized thinking and/or altered level of consciousness. Dementia has a slow onset, usually with normal attention. Depression involves loss of interest in previously pleasurable activities.
What interventions prevent delirium in the postop setting?
Early ambulation and pain control
The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client's place of worship. What is the priority nursing action?
Encourage the patient to talk about the trauma - The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to discuss the trauma at their own pace
The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the priority nursing action?
Give the child a written schedule of daily activities
What are the types of delusions associated with schizophrenia?
Grandeur - "I need to get to Washington for my meeting with the president." Control - "Don't drink the tap water. That's how the government controls us." Nihilistic - "It doesn't matter if I take my medicine. I'm already dead." Somatic - "The doctor said I'm fine, but I really have lung cancer." Reference - Cause clients to feel as if songs, newspaper articles, and other events are personal to them.
A new nurse is caring for an adolescent transgender client. What question would be appropriate when assessing the client's gender identity?
How would you describe your gender?
A client with moderate Alzheimer disease is started on memantine. In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following?
Improved ability to perform ADL's
An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate?
It's time to get back to bed now. - Appropriate communication techniques to assist a client with dementia while avoiding anxiety and other negative behaviors include reorientation in the earlier stage of dementia and validation in the later stage of dementia.
The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors?
Likes to be the center of attention, exaggeration emotional expression, little tolerance for frustration
The nurse is caring for a client admitted with abdominal pain, who has been diagnosed with somatic symptom disorder after a thorough evaluation finds no medical cause for the symptoms. Which intervention should the nurse include in the plan of care?
Limit time discussing physical symptoms with the patient - Nursing interventions include limiting discussion of symptoms and identifying secondary gains, factors that intensify symptoms, and coping strategies.
A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action?
Remain in the room with the patient
A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take?
Remain silent and allow the patient to leave (patient is showing a negative symptom)
The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom?
That song is a message sent to me in secret code - see examples of delusions
What are interventions used in caring fro a patient with acute manic episode?
The nursing care plan for clients with acute mania includes providing a quiet, structured, non-stimulating environment; engaging the client in one-on-one activities and physical activity; limiting contact with other people; and providing foods of high nutritional value that are easy to eat.
The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room." Which statement best explains the client's behavior?
The patient has an intense need to control the environment
The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. What is the best explanation for these clinical characteristics?
The patient is trying to maintain self esteem - The clinical characteristics of narcissistic personality disorder can best be explained as an attempt to maintain a fragile self-esteem that was damaged during childhood due to an environment that was highly critical, demanding, and fostered a sense of inferiority.
What are secondary gains in somatic symptom disorder?
To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: Redirect somatic complaints to unrelated, neutral topics Limit time spent discussing physical symptoms
The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take?
Ask the child to blow up a balloon - Nursing interventions include the following: Stay calm and remove the child from the source of frustration/anger Assist the child in calming down with deep breathing exercises Discuss what precipitated the behavior and why the behavior is wrong Discuss acceptable ways of expressing anger and frustration Acknowledge that controlling anger is difficult Provide rewards for appropriate behavior Discuss the consequences of inappropriate behavior
A nurse is admitting a child and observes multiple irregular bruises. Which action should the nurse take next?
Continue with a detailed interview and physical examination - If child abuse is suspected, the nurse should obtain a detailed history, perform a physical examination, and report signs of abuse. Parent-child interaction should be examined closely, and any inconsistencies between a parent's report and the actual findings should be documented.
The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data?
Diaphoresis Hallucinations Tachycardia
The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessments would support this diagnosis?
Difficulty concentrating Feeling detached from others Flashbacks of traumatic event Persistent angry, fearful mood
A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the best response by the nurse?
It is your responsibility to sign in when you return from a pass - Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. Nursing interventions include setting firm limits and making clients aware of the rules and acceptable behaviors.
After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction?
Place a chain lock on the door above or below the patient's eye level - The most effective strategy to prevent clients with dementia from wandering is to make modifications to secure their environment. These include installing locks above or below eye level on doors, hiding exits with wall hangings or curtains, placing a black mat in front of exits, and using doorknob covers, motion detectors, and alarms.
A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse?
Provide earphones and a DVD player and have the patient sing along with the music - Although antipsychotic medication is the first-line treatment for diminishing or eliminating psychotic symptoms, such as hallucinations, clients need other strategies for coping with distressing symptoms. - Increasing external auditory stimulation often helps distract the client from the internal voices and focus on reality.
A client with severe major depressive disorder is lying in bed and has not moved for 3 hours. The client will respond slowly to "yes" and "no" questions; otherwise, the client does not respond when spoken to. The clinical manifestations exhibited by the client are known as:
Psychomotor retardation - The key features include decreased movement, inability or decreased ability to talk, and impaired cognitive function.