Ch. 9-14 Mental health ATI book questions

Contacting the psychiatrist for invitation of commitment proceedings.

A client who has depression is admitted to treatment on a voluntary basis. While in the hospital, the client makes several comments about wanting to end it all. The client decides one day to leave against medical advice. Which of the following would be the most appropriate action by the nursing staff?

" Acquaintance rape often involves alcohol."

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?

If threats are made to an identifiable third party

When is a nurse legally obligated to breach confidentiality?

A jealous man states, "I am getting my gun and going to shoot my wife's lover!"

Which of the following client situations most urgently requires the nurse to break confidentiality and warn a third party?

A client who is addicted to alcohol who has two DUI offenses.

Which of the following clients would most likely be mandated outpatient treatment?

- When a client states that he or she intends to commit suicide and is making plans to do so. - When a client states that he or she intends to harm others by a deliberate act. - When a client is unable to control his or her rage and is assaulting everyone around him or her.

Which of the following would be circumstances when a client could be subjected to involuntary hospitalization? Select all that apply.

- depressed immune system - increased blood pressure -unhappiness

A nurse is discussing acute vs prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response?

" I will schedule the client for TMS treatment 3 to 5 times a week for the first several weeks."

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

- denial - bargaining - anger - depression

A charge nurse is reviewing Kubler-Ross: Five stages of grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply)

Right to freedom

A client made threats to harm his parents if they come too close to him. The parents called 911, and the client is now held involuntarily for a psychiatric evaluation. During this time of involuntary admission, the client retains all client rights except for which of the following?

He does not meet any of the necessary criteria.

A client was brought to the emergency department by police after neighbors complained that he was loud and disruptive. The client is paranoid and upset and states, No one can be trusted.î Which of the criteria for involuntary admission does this client meet?

leave the hospital after giving written notice of her intent to do so.

A client who had agreed to be hospitalized for depression problems has decided that now she wants to leave the hospital. The mental health staff caring for her realizes that at present she can legally

The client expresses a sense of unreality about the traumatic incident

A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect?

tension building phase

*Identify the Cycle of violence phase:* The perpetrator has minor episodes of anger and can be verbally abusive and responsible for some minor physical violence (pushing , shoving) As tension continues to grow, both partners try to reduce it. The perpetrator may turn to substances and the victim dismisses the significance of the violence The vulnerable person is tense during this stage and tends to accept the blame for what is happening.

Acute battering phase

*Identify the Cycle of violence phase:* The tension becomes too much to bear, and serious abuse takes place. The victim may provoke the perpetrator to reduce the unbearable tension The vulnerable person can try to cover up the injury or try to get help This stage is the most violent and shortest

Periods of escalation and deescalation

*Identify the Cycle of violence phase:* Usually continue with shorter and shorter periods of time between the two without interventions Emotions for the perpetrator and vulnerable person (fear or anger), increase in intensity. Repeated episodes of violence lead to feelings of powerlessness

" You'd better listen to me"

A nurse is conducting group therapy with a group of clients. Which of the following statements made by client is an example of aggressive communication?

" The client is at greatest risk for suicide during the first weeks of an MDD episode."

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Pregnancy increases the risk for violence from a spouse or partner."

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching?

Continue to refuse treatment Rationale: The client maintains the right to refuse treatment even if it is needed when she is not dangerous to herself or others.

A 22-year-old client has been manipulative of staff and disruptive in the milieu. Although she is not dangerous to herself or others, she has created problems on the unit and clearly is not making progress. The nurses offer prescribed medication, but she consistently refuses ìany drugs. The staff realizes that legally this client can..

Work with the client on grounding techniques Rationale: grounding techniques (stomping the feet, clapping the hands, or touching physical objects) are useful fir clients while have a dissociative disorder and are experiencing manifestations of derealization.

A nurse in acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse ass to the plan of care?

- memory loss - confusion

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply)

- defensive responses to questions - facial grimacing - agitation

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the *Preassaultive stage* of violence? ( select all that apply)

- emotional outbursts - difficulty making decisions

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply)

- excessive worry for 6 months - restlessness - sleep disturbance Rationale: generalized anxiety disorder is characterized by procrastination in decision making & muscle tension.

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

Move the client away from others.

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action?

" I am here to provide care and cannot accept this from you."

A nurse is caring for a client who has bipolar disorder. The client states. " I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make?

Monitor the client for escalating behavior

A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?

The client states that the furniture in the room seems to be small and far away.

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?

" Tell me about how you are feeling right now."

A nurse is caring for a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make?

- history of chronic bronchitis - recent death in clients family - family history of depression - personal history of panic disorder

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse indemnify as a risk factor for depression (select all that apply).

Stay with the client and remain quiet. Rationale: during a panic attack , quietly remain with the client. This promotes safety and reassurance without additional stimuli.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

" Stop screaming, and walk with me outside."

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client?

Request that other staff members remain close by.

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?

" You sound angry. Anger is a normal feeling associated with loss."

A nurse is caring for a client who lost a guardian to cancer last month. The client states, " I'd still have my guardian if the doctor would have made a diagnosis sooner." Which of the following responses should the nurse make?

" When I have to pick up extra work , I feel very overwhelmed. I need to focus on my own responsibilities."

A nurse is caring for a client who states. "I'm so stressed at work because of my coworker. I am expected to finish others work because of their laziness!" When discussing effective communication, which of the following statements by the client to coworker indicates client understanding ?

" you believe this wouldn't have happened if you hadn't been out alone?"

A nurse is caring for a client who was recently sexually assaulted. The client states, " I never should have been out on the street alone at night." Which of the following responses should the nurse make?

Advise the client about the location of safe houses and shelters.

A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority?

- " I may experience feelings of resentment." - " I will probably withdraw from others." - " I can expect to experience changes in sleep."

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply)

- difficulty sleeping can indicate a relapse. - participating in psychotherapy can help prevent a relapse - anhedonia is a clinical manifestation of a depressive relapse

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following infomration should the nurse include in the teaching? (Select all that apply)

" I will administer prophylactic treatment for sexually transmitted infections, like chlamydia."

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching?

Presence of manifestations for at least 2 years

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect?

- taking breaks - debrief with others following the incident

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Selecta ll that apply)

Bipolar disorder with rapid cycling

A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion?

- voice changes - cough - neck pain

A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects?

- offer concise explanations - establish consistent limits - use a firm approach with communication

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care?. (Select all that apply).

Assess the clients risk for self-harm Rationale: the greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self-harm or suicide. Therefore, the first action to take is to asses the clients risk for self-harm to ensure that the client is provided with a safe environment

A nurse is planning care for a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make?

Intentionally causing someone to fall is an example of physical violence

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?

Excessive stressors cause the client to experience distress

A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion?

- respiratory distress - retinal hemorrhage - altered level of consciousness - increase in head circumference Rationale: Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome.

A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? (Select all that apply)

" I will receive a muscle relaxant to protect me from injury during ECT." Rationale: a muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity .

A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?

Use assertiveness techniques

A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the clients situation?

"Cognitive reframing will help me change my irrational thoughts to something positive."

A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?

" I am aware that my PMDD causes me to have rapid mood swings."

A nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?

" ECT is effective for clients who are experiencing severe mania."

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicated understanding?

- interpersonal relationships - culture - religious beliefs - prior experience with loss

A nurse is working with a client who has recently lost a guardian. The nurse recognizes that which of the following factors influence a clients grief and coping ability? (Select all that apply)

Attempt to reduce anxiety

A nurse observed a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?

- round burn marks on forearms - areas of ecchymosis on torso

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. Which of the following finds should alert the nurse to possible abuse?(select all that apply)

Placing the client on one-to-one observation

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurses priority?

- difficulty concentrating on tasks - negative self-image - recurring nightmares

A nurse working on an acute mental health unit is caring for a client who has post traumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply)

Inappropriate; room restriction is not treatment in the least restrictive environment. Rationale: Clients have the right to treatment in the least restrictive environment appropriate to meet their needs. It means that a client does not have to be hospitalized if he or she can be treated in an outpatient setting or in a group home. It also means that the client must be free of restraint or seclusion unless it is necessary. Verbal and behavioral techniques should be instituted before physical measures such as sedation, restraint, or seclusion.

An adolescent on the unit is argumentative with staff and peers. The nurse tells the adolescent, arguing is not allowed. One more word and you will have to stay in your room the rest of the day. The nurses directive is.

1. Physiological needs 2. Safety 3. Belonging 4. Esteem/social needs 5. Self acutalization

In Maslows hierarchy what is the order in mental health?

" I cannot confirm or deny the existence of any client here." Rationale: The protection and privacy of personal health information is regulated by the federal government through the Health Insurance Portability and Accountability Act (HIPAA) of 1996

The nurse on an addictive disorders unit receives a phone call inquiring about the status of a client. The caller is not on the client's allowed contact list. Which of the following is the appropriate response by the nurse to the caller?

If a committed client is also found to be incompetent, he loses his rights under the Patient's Bill of Rights.

Two nurses are discussing the rights of hospitalized psychiatric clients. Which of the following statements is an error?

- gravely disabled - mentally incompetent - unable to provide basic needs when resources exist

Under which conditions would it be in the clients best interest for the court to appoint a conservator, or legal guardian? Select all that apply.