U World Mental Health

A 60 year old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. the client can state the name and address but has no recollection of the past 2 days. What is the "PRIORITY " nursing action? 1. Assess vital signs 2. Contact family member 3. Encourage the client to recall recent events 4. Perform a mental status assessment.

1. Assess vital signs Assessment of a client's physiologic status and needs is the priority nursing action when the client is suffering from Amnesia with no recollection of where he has been or what he has been doing for a period of time. Interventions need to be implemented to stabilize the client physically before psychosocial needs are addressed.

The student nurse is performing an assessment of a 10 year old diagnosed with attention deficit hyperactivity disorder. In addition to the Three core symptoms of ADHD ( hyperactivity, impulsiveness, and inattention) which of the following would the student nurse expect to find during the assessment? 1. Confusion and a learning disability 2. delayed physical and emotional development 3. disorientation and disorientation impairment 4. low self-esteem and impaired social skills

1. Confusion and a learning disability The diagnosis of ADHD includes the presence of hyperactivity, impulsiveness, and inattention. The negative consequences of the core manifestations include impaired social skills, for self-esteem, academic or work failure, increase risk of depression and anxiety, and increase the risk for substance abuse.

A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms? 1. Denial and projection 2. Rationalization and depression 3. Regression and displacement 4. Sublimation and reaction formation

1. Denial and projection The most common defense mechanisms used by persons with alcoholism is denial, refusal to accept the reality of threatening situations, or painful thoughts, feelings, or events. Projection involves placing one's own thoughts, feelings, or impulses onto someone else.

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder Which assessments would support this diagnosis? SELECT ALL THAT APPLY. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood

1. Difficulty concentrating 2. Feeling detached from others 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood A person suffering from post-traumatic stress disorder experiences 3-categories of symptoms: reexperiencing the trauma event, avoiding reminder of the trauma, and hyperarousal.

The nurse is conducting a seminar for parents of adolescents about health issues coming to this age group, which parent statement indicates that the adolescent may have bulimia nervosa? 1. I found several empty boxes of laxative in my child's wastebasket. 2. I have noticed my child has started wearing bulky, oversized clothing. 3. My child has lost 20 pounds in the past 2 months. 4. My child has stopped going to the gym.

1. I found several empty boxes of laxative in my child's wastebasket. Bulimia nervosa is an eating disorder characterized by episodes of binge eating followed by actions to prevent weight gain.

A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss? 1. I have signed up to be a dog walker when I normally would watch television. 2. I understand that losing weight would improve my health and well-being. 3. I want To lose 8 lb so then my formal gown will fit in 4 weeks. 4. My spouse and children are always encouraging me to eat healthier.

1. I have signed up to be a dog walker when I normally would watch television. Successful behavior modification requires client Readiness and motivation to change, as evidenced by the client developing and acting on a plan. Clients often do not initially see the need for change, but with the appropriate support they begin contemplating change, preparing to change, and then actively changing.

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What's the best response by the nurse? 1. I will help you get ready; then we can walk to the dining room together. 2. I'll have breakfast brought to your room. 3. It's Okay. You can join us when you are ready. 4. You'll feel better when you get up.

1. I will help you get ready; then we can walk to the dining room together. Clients with low energy, lethargy, or fatigue associated with major depressive disorder needs structure and direction in performing basic activities of daily living, including personal hygiene and grooming. The nurse needs to provide assistance to the client and completing adl's and in initiating social interaction with others.

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? 1. "Don't you know it's not morning yet?" 2. "It's time to get back to bed now." 3. "You might fall if you wander in the dark." 4. "You should not leave your room without assistance."

2. "It's time to get back to bed now." Appropriate communication techniques to assist 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.

A nurse working at a mental health clinic is reviewing four messages from clients requesting a same- day appointment. Which client does the nurse prioritize to call back first? 1. A client who experienced a panic attack for the first time in 6 months after a minor accident yesterday and is requesting a refill for alprazolam 2. A client who is experiencing a fever and diarrhea 2 days after the health care provider increased the sertaline dose 3. A client taking phenelzine who is concerned about food medication interactions and is requesting a list of foods to avoid 4. A client who has attention- deficit hyper activity disorder and is experiencing insomnia and irritability 2 days after starting methylphenidate

2. A client who is experiencing a fever and diarrhea 2 days after the health care provider increased the sertaline dose Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome.

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? 1. Childs favorite stuffed animal 2. Connect-the-dots puzzle book 3. Putting together a 300-piece jigsaw puzzle 4. Writing in a journal about the hospital stay

2. Connect-the-dots puzzle book Children with intellectual disabilities should be based on developmental age was consideration given to the child size, coordination, physical fitness, maturity, likes and dislikes, and health status.

A client with a 20-yr history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse? 1. How long has the oil been leaking from your head? 2. Let's go back to your room and look for your headband together. 3. There is not oil coming out of your head. 4. You are going to miss breakfast if you do not go into the dining room.

2. Let's go back to your room and look for your headband together. The priority nursing action for a client exhibiting anxiety is to intervene in a manner that helps make the client feel more at ease. Delusions are fixed, false beliefs; challenging a client's delusional content system will increase the client's anxiety ad will not change the client's beliefs.

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? 1. Advocate for an elimination diet to identify the cause of the symptoms 2. Limit time spent discussing physical symptoms with the pt 3. Reinforce negative examination results when pain medication is requested 4. When abdominal pain is mentioned, remind pt that it is not real

2. Limit time spent discussing physical symptoms with the pt Somatic symptom disorder occurs when stress causes medically unexplainable physical symptoms that disrupt daily life. Nursing interventions include limiting discussion of symptoms and identifying secondary gains, factors that intensify symptoms, and coping strategies.

A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake most of the night, feel exhausted, and do not know what to do." What is the best response by the nurse? 1. Do not let your mother take naps in the afternoon. 2. Our social worker can discuss long-term care options with you. 3. We can ask the health care provider for medication that will help your mother sleep. 4. Your mother can be cared for in a nursing home.

2. Our social worker can discuss long-term care options with you. Caregivers of clients with Alzheimer disease and other types of dementia often experience burnout due to stress and exhaustion. They need information on community resources that can provide assistance with client care.

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? 1. Give the client a book to read 2. Provide earphones and a DVD player and have the client sing along with the music 3. Tell the client that the voices will go away when the medication starts to work 4. Tell the client to ignore the voices

2. Provide earphones and a DVD player and have the client 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.

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? SELECT ALL THAT APPLY. 1. "I am focusing on my new hobby and my friends in the book club." 2. "I left and didn't awaken my spouse, who went back to sleep after turning off the alarm clock." 3. "I try to get up early and keep the children from being too loud in the mornings." 4. "If I didn't get so stressed about my job, my spouse wouldn't drink so much." 5. "When my spouse was sick, I called and rescheduled clients so my spouse could rest."

3. "I try to get up early and keep the children from being too loud in the mornings." 4. "If I didn't get so stressed about my job, my spouse wouldn't drink so much." 5. "When my spouse was sick, I called and rescheduled clients so my spouse could rest." Codependent spouses, friends, and family members can impede treatment progress of clients with substance use disorders. Codependent behaviors include making excuses for a client's drug/alcohol use, putting a client's needs before one's own, and not allowing a client to suffer the consequences of actions.

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead I can't believe this is happening." What is the BEST response by the nurse? 1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?" 3. "This has been very overwhelming for you. What are you feeling right now?" 4. "Well, you did find your spouse. You need to focus on helping your spouse get better"

3. "This has been very overwhelming for you. What are you feeling right now?" Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, ad confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions.

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 KEY clinical findings daily for at least 2 weeks? 1. Daily sleep disturbance or significant weight loss 2. Decreased ability to think or low energy 3. Depressed mood or loss of interest or pleasure 4. Thoughts of worthlessness or recurrent thoughts of death

3. Depressed mood or loss of interest or pleasure The 2 key clinical features of major depressive disorder (unipolar depression) are depressed mood and loss of interest or pleasure. One of these symptoms must be present daily for at least 2 weeks for the diagnosis of major depressive disorder to be made.

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? 1. Allow the child to stay home when the child seems particularly anxious 2. Encourage the parent/caregiver to sit in the classroom with the child 3. Insist on school attendance immediately, starting with a few hours a day 4. Return the child to school when the cause of the school phobia has been identified

3. Insist on school attendance immediately, starting with a few hours a day A child with school phobia needs to return to the classroom immediately. Insisting on school attendance, along with other supportive interventions, will help the child make a faster adjustment.

The clinic nurse reinforces education about intimate partner violence for a group of graduate nurses. Which of the following are appropriate for the nurse to include? Select all that apply. 1. Intimate partner violence is most common in low-income families 2. Intimate partner violence is rare in same-sex partnerships 3. The abusive partner often demonstrates jealousy and possessiveness. 4. Victims may not leave due to financial concerns or fear of harm by the abuser. 5. Violence against a female often intensifies during pregnancy.

3. The abusive partner often demonstrates jealousy and possessiveness. 4. Victims may not leave due to financial concerns or fear of harm by the abuser. 5. Violence against a female often intensifies during pregnancy. IPV is abusive behavior by one partner against the other in an intimate relationship. IPV occurs in all religious, socioeconomic, racial, and educational groups, are in both heterosexual and same-sex relationships. IPV often begins or intensifies during pregnancy. Victims often stay in the relationship due to fear, financial or child custody concerns, or religious beliefs, among other reasons.

The nurse is speaking with the spouse of a client following a family discussion with the healthcare provider about the clients terminal condition and eligibility for hospice care. The spouse states, " I don't think I can make this decision right now. What would you do?" How should the nurse respond? 1. I find it helpful to investigate the options. I will get you a pamphlet about Hospice Services. 2. It's hard to say what the best decision is, but I know hospice provides wonderful care. 3. These decisions are challenging. Tell me your spouse's beliefs about end-of-life. 4. You seem overwhelmed. I'll contact the chaplain to come and talk to you about the options.

3. These decisions are challenging. Tell me your spouse's beliefs about end-of-life. 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.

The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this." How should the nurse respond? 1. You can cry and get it all out; I will stay with you. 2. You have dealt with diabetes; you can conquer dialysis. 3. You sound very discouraged and frightened. 4. You still have a lot to live for; think About your family.

3. You sound very discouraged and frightened. Nurses should assist clients and process difficult news or events the discussion of thoughts and feelings. Reflecting is an appropriate technique that promotes open communication and encourages the client to recognize feelings.

The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse prioritize? 1. Acknowledges poor interpersonal skills 2. identifies new coping mechanisms 3. increase caloric intake to gain weight 4. verbalizes sources of conflict and anger

3. increase caloric intake to gain weight Treatment for a client requiring hospitalization for anorexia nervosa should focus on a short-term outcomes of increasing caloric intake, promoting gradual weight gain, and addressing medical conditions caused by starvation.

A recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following responses by the nurse are appropriate? Select all that apply. 1. "A friend of mine passed away recently. I know how hard losses can be." 2. "I see that you're upset. I will step out while you process these feelings." 3. "It may take a while, but coming to terms with loss gets easier with time." 4. "This is a difficult time. Tell me about how you have been coping." 5. "What are your thoughts about attending a grief support group?"

4. "This is a difficult time. Tell me about how you have been coping." 5. "What are your thoughts about attending a grief support group?" Nurses should use therapeutic communication techniques (ex. reflecting, asking open-ended questions, suggesting strategies or resources) to support clients' psychosocial needs and build the nurse-client relationship. Minimization, automatic responses, and leaving clients who are sharing strong emotions are non therapeutic actions

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? 1. Ask where the client is going 2. Immediately follow the client out the door 3. In a loud voice, direct the client to come back to the room 4. Remain silent and allow the client to leave

4. Remain silent and allow the client to leave Social isolation and impaired social interaction are common negative symptoms of schizophrenia. The client will seek to be alone to relieve anxiety associated with being around others. The nurse needs to be accepting of the client's behavior and continues attempt at brief contact until the client is comfortable.

A nurse is caring for a client who was admitted following a failed suicide attempt. Which client statement is most concerning? 1. I don't think that I will ever be okay again. 2. I feel so angry because I failed at my attempt. 3. I have been sleeping all the time lately. 4. Very soon everything will be much better.

4. Very soon everything will be much better. Clients who have attempted suicide are at risk for repeated attempts and completion of suicide. The nurse should assess the client's behaviors ad comments, and if a client has a sudden positive outlook, the nurse should directly ask about a suicide plan.

The nurse assess a pediatric client and finds bruises in various stages of healing on the back and legs. When questioned about the bruises the child begins to cry and states, "Somebody did things to me." Which of the following communications by the nurse is appropriate? Select all that apply. 1. How long have your parents been doing things to you? 2. Tell me about what happened. I promise not to tell anyone. 3. This is terrible. Whoever did this to you will be sorry. 4. What happened is not your fault. You are not to blame. 5. You did the right thing by telling me. You are not in trouble.

4. What happened is not your fault. You are not to blame. 5. You did the right thing by telling me. You are not in trouble. When interviewing a child about abuse, the nurse should affirm that the child is not at fault or in trouble and avoid making assumptions or communication anger, shock, or disapproval. The nurse should be direct and honest about the requirement to report abuse.

The nurse cares for a client who has a do-not-resuscitate prescription, and notes extensive skin mottling and vital signs consistent with impending death. The client's spouse states, "i hope my spouse can hang on a little longer; our anniversary is in 2 days." What response by the nurse is appropriate? 1. Tell me about your favorite anniversary memory that you shares. 2. That would be very special, but please understand that it may not happen. 3. We never know; death happens in its own time despite what we may want. 4. Your spouse's body is shutting down and the time is near; I will stay here with you.

4. Your spouse's body is shutting down and the time is near; I will stay here with you. When assisting a client's family through the dying process, the nurse should provide factual, open, and honest communication; help the family anticipate what is happening and when death is imminent; and use the therapeutic technique of offering self.

A nursing home client with major depressive disorder reports difficulty going to sleep until late at night. The client gets up, paces the hallway, wrings the hands, and appears teary. What interventions should be included in the client's nursing care plan? Select all that apply. A. Allow the client to receive at least 20 minutes of natural sunlight each day B. Encourage the client to take naps during the day to make up for lost sleep C. Have the client engage in strenuous physical exercise just before bedtime D. Spend time with the client in a quiet environment just before bedtime E. Suggest that the client take a warm bath before going to bed

A. Allow the client to receive at least 20 minutes of natural sunlight each day D. Spend time with the client in a quiet environment just before bedtime E. Suggest that the client take a warm bath before going to bed Non-pharmacological strategies for improving sleep hygiene including exercising during the day, engaging and a relaxing activity before bedtime, having a relaxing sleep environment, avoiding naps during the day, avoiding caffeine after noon, and receiving at least 20 minutes of sunlight each day.

The nurse in a psychiatric clinic is evaluating the client's response to treatment for somatic symptom disorder with cardiac manifestations. Which client statement indicates a need for further treatment? A. I'm looking for another heart specialist to evaluate my symptoms B. I ask my spouse for support while I deal with my mother's death C. I have start carrying a sketchbook to draw whenever I feel upset D. I journal daily abt my stress level and any cardiac related symptoms

A. I'm looking for another heart specialist to evaluate my symptoms Somatic symptom disorder (SSD) occurs when psychological stresses manifest as physical symptoms of illness without physiological cause. Treatment has been effective if the client with SSD is able to identify alternate support systems for stress, identify perceived benefits of behaviors, employ stress management strategies, and verbalize factors associated with symptoms.

The nurse is conducting a follow-up interview with a client who is being treated for depression and suicidal ideation. Which factor best indicates the client is not currently at risk for suicide? A.) Client claims to have more energy and vigor since starting therapy B.) Client has clear future plans involving personal goals and family milestones C.) Client has signed a contract promising not to commit suicide D.) Client reports losing amitriptyline and requests a refill

B.) Client has clear future plans involving personal goals and family milestones Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric medications, overall effect, and energy level. Clients who articulate long-term personal goals are less likely to commit suicide.