Prep u chapter 9

During the initial assessment of a client with a mental health disorder, what would be the priority information for the nurse to obtain? (Select all that apply.)

-preexisting mental health disorders -current mental health disorders

The nurse is caring for a client who is a victim of intimate partner violence. The nurse determines the client has successfully developed a safety plan when the client makes which of the following statements?

"I have a packed bag ready, just in case."

A nurse is conducting an initial interview with a client who has paranoid delusions. What statement by the nurse can help to establish rapport as well as alleviate some of the suspicion the client may experience?

"I will be asking you a series of questions that I ask of all of my clients."

A nurse is reviewing a depression questionnaire completed by a client. Which of the following would the nurse interpret as being suggestive of depression?

"It usually takes me over an hour to fall asleep."

A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client?

25

A nurse is preparing to discuss the cycle of violence with a group of women who have been victims of abuse. Which of the following would the nurse include as part of phase 3 of this cycle?

A reconciliation period

When providing care to a victim of abuse, which of the following would the nurse do?

Allow the woman to participate in her care.

A older adult client is brought to the clinic by the client's daughter who voices concerns about changes in her parent's mental status. What behavior would the nurse look for to formulate a plan of care for dementia in this client?

Defers to family members to answer questions directed to the client

The nurse is admitting a client to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?

Do you have any thoughts of wanting to harm or kill yourself

A 75-year-old male client is admitted to the hospital with confusion. The client's adult child states that their father has been becoming more confused for the past few months. The child states "they keep forgetting to pay their bills and are unable to manage a budget, and they are constantly making poor decisions. I don't know what to do." The client is able to state their name and date of birth but appears confused about where they are and why, and the current date. The client also has difficulty with word finding and carrying on a conversation. For each finding, click to specify if the finding indicates an age-related change or Alzheimer Disease. Findings may support more than one classification.

Forgetful at times: Age-Related Change and Alzheimer Disease Unable to manage a budget: Alzheimer Disease Constantly making poor decisions: Alzheimer Disease Unable to state where they are or why or the current date: Alzheimer Disease Difficulty carrying on a conversation: Alzheimer Disease

During the review of systems within the comprehensive health history, the nurse notes that a client has multiple previous injuries and accidents. Which of the following issues is a priority in the nurse's assessment?

Investigate the possibility of physical abuse

The nurse prepares an educational session for staff on Alzheimer disease. What should the nurse include as a warning sign of this disorder? Select all that apply.

Losing the ability to balance a checkbook Asking the same question over and over again Forgetting how to cook or perform a routine activity Repeating the same story word for word again and again

The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding?

Nerve damage caused by repeated eye injuries

The nurse uses the SAD PERSONAS to assess the suicide risk for a client. The total score was 3. Which interpretation by the nurse is correct?

The client is at low risk for suicide.

Which type of elder abuse involves leaving an older adult and no longer providing care for the individual?

abandonment

A nurse is working with a woman who has been abused by her husband. Which of the following is a physiological sign commonly associated with abuse

hypertension

A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following?

judgment

The nurse reviews data collected on a client who is being admitted again for treatment of injuries caused by intimate partner violence. Which diagnosis should the nurse identify as being the most appropriate for this client?

low self-esteem

The client exhibits auditory hallucinations while the nurse is performing a mental health assessment. The nurse should document this as an alteration in which component of the mental health assessment?

perception

An emergency department nurse suspects a young client may be a victim of human trafficking when the nurse observes which of the following? Select all that apply.

unable to state month or day not allowed to speak for themselves seems fearful and anxious appears malnourished