RN Mental Health Online Practice 2023 A

A nurse on a mental health unit is caring for a client who has schizophrenia. After reviewing the client's medical record, the nurse should notify the provider of which of the following findings? Select the 5 unexpected findings that require notification of the provider.

elevated temperature, hypoactive bowel sounds, a decreased ANC level, myalgia along with an increased heart rate

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?

Anhedonia

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning."

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide?

"It is easier to talk about my feelings now."

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 teaching 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 an understanding of the teaching?

"I will update the plan of care as a client's manifestations of depression change."

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?

"If you do my homework for me, I won't bother you for the rest of the day."

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."

A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

1.5

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?

A client was administered one-half of the prescribed dose of medication.

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report?

A client who has borderline personality disorder threatened to harm their roommate.

A nurse on an acute mental health facility is receiving a change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who is experiencing delusions of persecution

A nurse is caring for a group of clients. Which of the following findings should the nurse report?

A client who is taking lamotrigine and has developed a rash

A nurse is preparing to administer prescribed clozapine to a client. Which of the following client laboratory results should the nurse review prior to administering the clozapine.

Absolute neutrophil count

A nurse is caring for a client who has impaired cognition. A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Anticipated- approach from front, give directions to the client, decrease sensory, assign client to a room contra- use a vest, ensure the bed is kept, keep the lights off non- provide the client with high

A nurse is caring for a client who has a personality disorder. For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Anticipated: Haloperidol, calmly approach non: requests change contra: hold next dose, dig

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 interdiscplinary services for the client at home?

Assertive community treatment

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL (0-50 mg/dL). Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

Blood pressure 154/96 mm Hg

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.

A nurse is caring for a client who has a personality disorder. The nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply.

Conduct debriefing with the client and other staff Maintain continuous observation of the client while in restraints

A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?

Dark urine

A nurse is caring for a newly admitted client.For each potential assessment finding, click to specify if the finding is consistent with positive or negative symptoms of schizophrenia.

Delusions of grandeur, clang associations, and catatonia are potential assessment findings of positive symptoms Alogia and withdrawal from social activities are potential assessment findings of negative symptoms

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 assessment findings supports the nurse's suspicion of delirium?

Easily distracted

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Emotional lability

A nurse is admitting a client who has anorexia nervosa and is at 60% of their ideal body weight. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to drink 125 mL of fluid each hour while awake.

A nurse in a mental health facility is caring for a client who requires the use of restraints. Which of the following actions should the nurse take when caring for the client?

Ensure a staff member checks on the client every 15 min.

A nurse in an inpatient mental health facility is caring for a client. The client begins pacing with their fists clenched and is verbally abusing the staff. Which of the following actions should the nurse take?

Ensure security personnel are available in the background to assist if the client's behavior escalates.

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 of isolation

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?

Gather supplies for endotracheal intubation.

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 include to reduce anxiety among the group members?

Guided imagery

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?

Hypertension

A nurse is caring for a client in an outpatient psychiatric clinic who has been applying a selegiline 12 mg transdermal patch once daily. Complete the following sentence by using the lists of options.

Hypertensive crisis Consuming foods high in tyramine

A nurse is caring for a client who has a personality disorder. The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not changed, or has declined.

Improved: Client follows instructions of the nurse, Client verbalizes precipitating factors to violent outburst no change: Client is silent and glaring at staff declined: Client attempts to bite nursing staff when offered water

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 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?

Inform the client that this admission is confidential.

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)?

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 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

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

Monitor the client's cardiac rhythm during the procedure.

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.

A nurse is planning care for a client who has made repeated physical threats toward 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. Which of the following ethical principles should the nurse apply in this situation?

Nonmaleficence

A nurse is caring for a client who has a personality disorder.For each potential provider's prescription, click to specify if the prescribed therapy is expected with obsessive compulsive disorder, dementia, or borderline personality disorder. Each therapy can support more than one disease process.

OCD: systematic desensitization, fluoxetine dementia: vlidation therapy, donepezil BPD: dialectical behavior, fluoxetine

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 planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?

Promote the use of music to compete with the client's auditory hallucinations.

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?

Reduce environmental stimuli.

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?

Set realistic limits on the client's behavior.

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?

Spending adequate time with a client who is verbally abusive

A nurse is caring for a client who has a personality disorder. Select the 6 findings in the client's medical record that are manifestations of the client's diagnosed personality disorder. Stealing money from family to cover credit card charges Exercises twice a week Anxious if left alone Same job for 12 years Well-nourished female Hypersexualization Well-groomed Married multiple times Incidences of self-injury Physical altercations

Stealing money, anxious if alone, hypertextualization, married multiple, self-injury, physical altercations

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.

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 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?

The client has COPD.

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors?

The client is interested in what the nurse is saying.

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?

The client needs excessive external input to make everyday decisions.

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.

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

WBC count 2,500/mm3 (5,000-10,000/mm3)

A nurse is caring for a client who has panic disorder. Click to highlight the findings in the medical record that indicate maladaptive uses of defense mechanisms.

When recognizing cues, the nurse should identify the client returning from exercise and being in an agitated state is the client demonstrating the maladaptive use of a deference mechanism. The nurse should also identify when the client tells them that the exercise instructor was one of their favorite people and had so much in common, but no one sees their true nature and that she is evil is the client demonstrating the maladaptive use of splitting.

A nurse is caring for a client who has posttraumatic stress disorder and a new prescription for sertraline. A nurse is monitoring a client who began taking sertraline 3 days ago. Which of the following findings should the nurse report to the provider as potential adverse effects of this new medication? Select all that apply.

increased temperature, decreased sodium level, diaphoresis, insomnia, headache, and elevated blood pressure

A nurse is caring for a client who has a personality disorder. Complete the following sentence by using the lists of options.

violent behavior increased agitation