HESI N260

A 65-year-old female complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?

"Are you ever alone when you hear these voices?"

The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?

"Black-out" after one drink last night on a date

The nurse is leading a "current events group" with chronic psychiatric clients. One group member states, " Clara Barton was my nurse during my last hospitalization. She was very mean nurse and wasn't nice to me." Which response would be best for the nurse to make?

"Clara Barton started the American Red Cross."

A 72-year-old female is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment?

"I will die If my cat dies."

The nurse plan to help an 18-year-old female intellectually disable client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse. "Get out of here I'll get up when I'm ready!" Which response is best for the nurse to make?

"I'll be back in 30 minutes to help you get out of bed and walk around the room."

A male client admitted to a mental health unit Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide to the client?

"Let me call and leave a message for your healthcare provider."

The is concluding discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?

"Only my belief in God can help me."

A male client who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of the medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicated a need for health teaching?

"When I return from my tropical island vacation. I will go to the clinic to get my Prolixin injection."

At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kind of things she would like to do with the group. The older women shrugs her shoulders and says. "You tell me, you're the leader". What is the best response for the nurse to make?

"Yes. I will be leading this group. What would you like to accomplish during this time?"

A client admitted with a diagnosis of depression. The nurse knows that which characteristics is most indicative of depression?

A negative view of self and the future

An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?

Accompany her outside for an increasing amount of time each day

An adolescent who attempted suicide with a drug overdose arrive in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?

Administer acetylcysteine (Mucocyst)

Over a period of several weeks. one male participant of a socialization group at a community daycare center for the elderly monopolizes most of the groups time and interrupts others when they are talking. What is the best action for the nurse to take in this situation.

Allow the group to handle the problem

Within several days of hospitalization, a client is repeatedly washing the top of the same table.. which intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?

Allow time for the ritualistic behavior, then redirect the client to other activities.

A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this clients plan of care?

Ask one of the nurses to spend some time with the client daily

The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently the client viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the clients history upon admissions to the hospital?

Ask the client if he has taken St. John's Warts routinely.

A client who is on a 30-day commitment to a drug rehab unit, ask the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. What responses are appropriate for the nurse to use? (select all that apply)

Ask the client to talk about what is causing him to be upset Remind the client of the unit rules

A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states. "No. It's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take?

Assess the content of the hallucination by asking the client whats wrong

The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would best in helping this client with his depression?

Assist the client in exploring feelings of shame, anger, and guilt

At a support group meeting of parents of a teenager with polysubstance dependency, a parent states, " Each time my son tries to quit drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse response should be based on which information?

Careful monitoring should be provided during withdrawl from the drugs

The client with depression asks the nurse. "What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain." What information should the nurse use tot support an explanation of neurotransmitters?

Chemical messengers that cause brain cells to turn off

A client who is known to abuse drugs is admitted to the psychiatric unit. which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?

Chlordiazepoxide (Librium)

A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameter reveals no significant change and the nurse formulates the diagnosis. "Confusion related to ICU psychosis." Which intervention would best be to implement?

Cluster care so that brief periods of rest can be scheduled during the day

A homeless person who is in the main phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the health care provider?

Decreased thyroid stimulating hormone levels

A nurse is teaching a female client who is in a homosexual relationship about women's health. Which topic is the most important for the nurse to address?

Domestic violence interventions

A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state someone is trying to steal his clothing. The most important action for the nurse to take is to

Encourage the client to actively participate in assigned activities on the unit

A 6-year-old girl with severe defects who is mentally disabled is brought to the emergency room because of a broken arm. The caregiver reports that the girls sustained injury when she fell from her wheelchair. Which intervention is most important for the nurse to implement"?

Evaluate the child for other injuries

A client receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?

Excessive CNS stimulation will be reduced

An adult client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance for his every move. Which response is best for the nurse to provide.

Go to occupational therapy and start a project

A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

He is unresponsive to instructions and is unable to cooperate with emetic therapy

A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse. "i know you are trying to poison me with food." Which response would be most important for the nurse to make?

I'll leave your tray here. I am available if you need anything else.

The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

If he might of taken any other drugs

A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client blood pressure increase, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate.

Immediately transfer the client to the ICU

The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is common?

Inability to recognize one's location.

The nurse is planning discharge for a male client with schizophrnia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?

Ineffective denial related to situational anxiety

A male client tells the nurse that he has plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement?

Inform the healthcare provider and document the plan in the record

A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic should the nurse take?

Inquire about the emotional factors affecting the client's present condition.

The nurse is assessing a clients intelligence. which factor should the nurse remember during the part of the mental status exam?

Intelligence is influenced by social and cultural beliefs

The wife of a male client recently diagnosed with schizophrenia ask the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member?

It is a chemical imbalance in the brain that causes disorganized thinking

When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate). It is most important for the nurse to include which instructions.

Keep your dietary salt intake consistent

An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide?

Let's go back to the activity room and see whats going on in there

The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?

Maintain safety in the clients milieu.

The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

Medication Managment

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all the time. I don't know what to do about my problems. I haven't been able to sleep at night and hardly eaten for the past 3 to 4 days." The nurse should initiate a referral based on which assessment?

Moderate level of anxiety

A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?

Notify the healthcare provider of the symptoms prior to the next administration of the drug

A 45-year-old male client tells the nurse he used to believe he was Jesus Christ but now he knows he is not. Which response is best for the nurse to make?

Others have similar thoughts when under stress

On admissions to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-four hours after admission the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?

Participate in a group quilting project

A 27-year-old female client is admitted to a psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this clients plan of care?

Provide a structural environment with little stimuli

A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could have happened because the man is her best friend. After acknowledging the clients fear and anxiety. How should the nurse respond?

Rape is not limited to strangers and frequently occurs by someone who is known to the victum

A female client refuses to take an oral hypoglycemic agent because she believes the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?

Reassess clients mental status for thought processes and content

A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take?

Redirect the client's energy by asking him to tidy the recreation room

A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vitals are: temperature 100F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?

Risk for injury related to alcohol detoxification.

Which diet selection by a client who is depressed and taking MAOI inhibitors tranylcypromine (Parnate) indicated to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

Roast beef, baked potato with butter, and ice tea

A 30-year-old sales manger tells the nurse. "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow developmental stage is the sales manager attempting to achieve?

Self actualization

The nurse should include which intervention in the play of care for a severely depressed client with neurovegetative symptoms? (Select all that apply)

Speaking slowly and simply,Allow the client extra time to complete task, Observe and encourage food and fluids, Encourage mild exercise and short walks on the unit, permit rest periods

A 19-year-old female client with diagnosis anorexia nervoua wants to help serve dinner trays to other clients on a psychiatric unit. Which action should the nurse take?

Suggest another way for this client to participate in the unit activities

Physical examination of a 6 year old reveals several bite marks in various locations on his body. X-ray examination revealed healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most important.

Tell me more specifically about your child's accidents

An elderly client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "take me home. I want my Mommy." Which response is best for the nurse to provide

Tell the client that the nurse is there and will help her

A male client tells the nurse that the voices he hears are saying " You must kill yourself." To assist the client in coping with these thouhgts. which response is best for the nurse to provide

Tell yourself that the voices are unreasonable

A client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use. the client tells the nurse, "i don't think I will ever be able to kick this habit" how should the nurse respond?

The client must participate in making decisions about his/her own physical and mental health.

Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IMfluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and familyabout this change in medication regimen?

The effects of alcohol and drug interaction

A nurse working in the emergency room of a children hospital admits a child whose injuries could have resulted from abuse. Which statement accurately describes the nurse's responsibility in cases of suspected child abuse?

The nurse should report any case of suspected child abuse to the charge nurse

The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns in his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicious?

The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

Which statement about contemporary mental health nursing practice is accurate?

The psychiatric nursing client may be an individual, family, group, organization, or community.

A female client with depression attends groups and states that she sometimes misses her medication appointment because she feels very anxious about riding the bus. Which statement is the nurse's best response?

What are some ways that you can cope with your anxiety?

The nurse observes a female client with schizophrenia watching the news on TV. She beings to laugh softly and says. "Yes, my love, I'll do it." When the nurse questions the client about her comment she states "The news commentator is my lover and he speaks to me each evening. Only I can understand what he is saying." What is the best response for the nurse to make?

What do you believe the new commentator said to you?

A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husbands states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. The client is displaying symptoms of what condition?

agoraphobia

a client is told that her infant will be stillborn.. what is the most important action for the nurse to implement after the birth

ask the family if they would like to see and hold the infant after birth

A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse "Please let me go I must leave because the secret police are after me." which is best for the nurse to make?

come with me to your room and I will sit with you

A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and ask the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (select all that apply)

compulsions relieve anxiety, anxiety is the key reason for OCD, obsessive thoughts are linked to levels of neurochemicals, antidepressant medications increase serotonin levels

A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his parents his reason for the assault. he replies "Because he was mad!" Which goal is best for the nurse to include in the client's plan of care? The client will

control impulsive actions toward self and others

the nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is like to be most beneficial for this client?

coping skills

A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking cannot remember who he is and exhibits multiple personalities. The nurse knows that these behaviors are often associated with

disscoataite disorder

The nurse should hold the next scheduled dose of a child's haldoperidol (Haldol) based on which assessment findings?

fever of 102 F

A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client mental status. Which assessment finding is most characteristic of a client with schizophrenia?

flat affect

which action should the nurse implement during the termination phase of the nurse-client relationship

help summarize accomplishments

A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has dual diagnosis. Which person is best for the nurse to refer this client to first?

his case manager

A client who has been admitted to the psychiatric unit tells the nurse, "My problem are so bad that no one can help me." Which response is best for the nurse to make?

how can i help you?

A client on the psychiatric unit appears to imitate a certain nurse on the unit.. the client seeks out this particular nurse and imitates her mannerisms.. the nurse knows that the client is using which defense mechanism

identification

The nurse is assessing the parents of a nuclear family who are attending a support group for parents and adolescents. According to Erikson these parents who are adapting to middle adulthood should exhibit which characteristics

increased self-understanding

A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

low self-esteem

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug would the nurse expect this client to make?

my mouth feels like cotton

which action should the nurse implement first for a client experiencing alcohol withdrawl

prepare the enviornment to prevent self-injury

A child is brought to the emergency room with a broken arm. Because of these injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child mother becomes very loud and shouts."I won't leave my son! Don't you touch him! You'll hurt my child." What is the best interpretation of the mother's statement? The mother is

projecting her feelings onto the nurse

On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder?

psychotic

The nurse observes a client who is being admitted to the mental health unit and identifies that the client is talking continuously using words that rhyme but that have no context or relationship with one topic to the next in the conversation. The client behavior and thought processes are consistent with which syndrome

schizophrenia

which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client?

self analysis

A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to admission. According to Erikson theory of psychosocial development, which stage is the client in at this time?

stagnation

a client who is admitted with the chief complaint fo feeling depressed tells the nurse, "I want to fell normal again." How should the nurse repsond?

tell me more about how things are with you