Saunders PN Mental Health

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

Use an indirect light source and turn off the television.

The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply.

-Hallucinations -Delusions -Neologisms

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement?

"Are you fearful and think that others may want to hurt you?"

An unlicensed assistive personnel (UAP) is assigned to work with the nurse to care for a client who is at risk for suicide. Which statement made by the UAP indicates to the nurse that the UAP understands suicide?

"Discussing suicide with a client is not harmful."

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?

"I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?

"I cannot promise to keep a secret."

The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?

"It seems as if you or your daughter feel regret?"

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which?

"Our relationship is a therapeutic and a helping one."

A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?

"Perhaps you could just enjoy the music without singing."

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client?

"Tell me about your difficulty sleeping."

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate?

"What do you mean by that?"

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client?

"You're feeling angry that your family continues to hope for you to be 'cured'?"

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client?

"You've been feeling like a failure for a while?"

The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply.

-Avoidance -Hyperarousal -Reexperiencing

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

-Communicate expected -Follow through -Assist the client -Be clear w/ the client

A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply.

-Cutoffs -Conflict -Over involvement

While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of the National Association of Anorexia Nervosa and Associated Disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.

-I'm going to do whatever... -I'll go and participate...

An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply.

-Is it in the best interest of society? -Does its use violate the client's rights? -Is this therapy in the best interest of the client?

The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?

-Let me know if you change your mind...

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply.

-Looks at old snapshot of family -Visits the spouse's grave once a month -Visits the senior citizens' center once...

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen. The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply.

-Making -Providing -Ensuring

Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply.

-Medication management -Monitoring and Documenting Behavioral -Notifying the health care provider... -Planning care for the needs of those...

The nurse is caring for a client who is diagnosed with anxiety. The nurse knows that according to Hildegard Peplau, there are different levels of anxiety that include which? Select all that apply.

-Mild -Panic -Severe -Moderate

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be nontherapeutic? Select all that apply.

-Minimizing -Changing -Asking

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply.

-Monitor vital signs -Provide a safe environment -Address hallucinations -Provide reality orientation

The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply.

-Mutual Learning -Increased Feedback -Instilling a sense of belonging -An opportunity to practice...

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

-My husband always brings... -I have bruises all over my... -My boyfriend yells and ...

The nurse is collecting data on a newly admitted client with conversion disorder. The nurse knows which voluntary motor or sensory function deficits might be present in this client? Select all that apply.

-Paralysis -Blindness -Paresthesia -Movement Disorder

Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply.

-Poor limited setting -Staff inexperience -Provocative or controlling staff -Arbitrary revocation of privileges

The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which reason?

-Protection from the risk of intimacy

The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply.

-Provide -Decrease -Restrict

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.

-Restating -Listening -Maintaining neutral responses -Providing acknowledgement and feedback

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.

-Risk for injury -Risk for infection -Risk for aspiration -Impaired verbal communication

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply.

-Severe -Extremeley -Desire for -Delirium -Severe drug reactions...

The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

-Stay with the client -Administer anxiolytics medications -Ensure the client is in an environment...

The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.

-Suicide is a frequent cause of death among the older population. -Some indications of dementia may actually originate as depression. -Depression in an older person is likely to have physical manifestations.

The nurse is gathering data from a client diagnosed with a phobia. Which are some of the clinically recognized names of common phobias? Select all that apply.

-Zoophobia -Xenophobia -Agoraphobia -Glossophobia

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Alzheimer's disease

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

The nurse employed in a psychiatric unit receives a client assignment for the day. Which client assigned to the nurse is at the highest risk for committing suicide?

A client with severe depression and terminal cancer

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the primary health care provider (PHCP).

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?

Accept the client as a person and make the client feel safe.

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse?

Agoraphobia

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase?

Assist with making appropraite referrals

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?

Avoid joking or laughing in the presence of the client.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action?

Call the nursing supervisor

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis?

Conversion disorder

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism?

Denial

The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations?

Discuss common fears and questions expressed by other clients with the same diagnosis.

The nurse is caring for a client with severe depression. Which activity is appropriate for this client?

Drawing

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention?

Escort the manic client to his or her room.

The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place priority on which action when planning care for this client?

Establish a trusting nurse-client relationship.

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention?

Feed, bathe, and dress the client as needed until the client can perform these activities independently.

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving.

An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?

I am concerned about you. Are you...

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?

I can't tell you that (or similar wording)

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action?

Increasing the level of suicide precautions

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client and offer to take her for a walk.

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?

Look for organic causes of the paralysis.

A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room and talk about his feelings.

An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, which is the priority nursing action?

Notify the social worker to...

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

The parents of a teenager diagnosed with anorexia nervosa ask the nurse what part they can play during the long recovery period. The nurse accurately relates that which actions should the parents take?

Planning a non-food related activity

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?

Psychomotor retardation and side effects of medication

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action?

Quietly approach the client, escort her to her room, and assist her in getting dressed.

A client is admitted to the psychiatric unit following a serious suicide attempt by a drug overdose. Which action should the nurse implement?

Remain with the client at all times

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?

Removing the client from any immediate danger

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need?

Safety and Security

The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial?

Share the observation with the client and help the client recognize his or her feelings.

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention?

Sit beside the client in silence and verbalize occasional open-ended questions.

The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client?

Sounds like you're feeling pretty troubled...

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?

Tell me more about what causes you to...

The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a DVD and a cherished autographed picture of the performer.

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand ...

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note?

The client presents a harm to self.

A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction?

The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note?

The client will participate in the treatment plan.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?

The false belief that one is being singled out for harm by others

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion?

The mother should restrict the amount of chocolate and caffeine products in the home.

The nurse in the emergency department is assisting in caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. Which interpretation should the nurse make of these behaviors?

They are expected reactions to a devastating event.

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. Which is important for the nurse to understand when planning?

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action?

Use a night light and turn off the television.

The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse plans to use which communication technique when developing strategies that will promote adequate nutrition and encourage the client to discuss feelings?

Use open-ended questions and silence.

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment?

Weight loss

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate?

What do you and your husband believe....

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement?

What do you find difficult about this situation?

A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response?

What do you mean by that?

The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time?

You sound very unhappy. Are you thinking of harming yourself?

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

You sound very upset. Are you thinking...

The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?

reported hopelessness