mental exam 1

A client taking lithium reports vomiting, abd pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse plans care based on which representation of this level? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal

1

The nurse is planning care for a client being admitted o the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions. 2. Suicide precautions with 30 min checks. 3. Checking the whereabouts of the client every 15 mins. 4. Asking the client to report suicidal thoughts immediately.

1

When review the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntary. Based on this type of admission, the nurse should provide which intervention for this client? 1. Monitor closely for harm to self/others. 2. Assist in completing an application for admission. 3. Supply the client with written info about his/her mental illness. 4. Provide an opportunity for the family to discuss why they felt the admission was needed.

1

A client's medication sheet contains a prescription for sertaline. To ensure safe administration of the medication, how should the nurse administer the dose? 1. On an empty stomach. 2. At the same time each evening. 3. Evenly spaced around the clock. 4. As needed when the client complains of depression.

2

The police arrive at the ED with a client who has lacerated both wrist. Which is the initial nursing action? 1. Administer an antianxiety agent. 2. Assess & treat would sites. 3. Secure & record a detailed history. 4. Encourage & assist the client to ventilate feelings.

2

The nurse calls security & has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment

2, 3, 5

A hospitalized client is started on phelzine for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies

3, 5

On review of the client's record, the nurse notes that the admission as voluntary. Based on this info, the nurse plans care anticipating which client behavior? 1. Fearfulness regarding treatment measures. 2. Anger & aggressiveness directed toward others. 3. An understanding of the pathology & symptoms of the diagnosis. 4. A willingness to participate in the planning of the care & treatment plan.

4

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicate that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitutes a crisis for another client.

4

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1. Restating 2. Listening 3. Asking "why" 4. Maintaining neutral responses 5. Providing acknowledgment & feedback 6. Giving advise & approval/disapproval

1, 2, 4, 5

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process. 2. Rapid heartbeat or anxiety. 3. Alcohol withdrawal symptoms. 4. Thought broadcasting or delusions.

2

The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complications? 1. Parkinsonism 2. Tardive dyskinesia 3. HTN crisis 4. Neuroleptic malignant syndrome

2

A female victim of 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 is the most appropriate nursing response? 1. You need to be realistic. The rape did not just occur. 2. It will take some time to get over these feelings about your rape. 3. Tell me more about the incident that causes you to feel like the rape just occured. 4. What do you think that you can do to alleviate some of your fears about being raped again?

3

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client experiencing anxiety as a result of a situation crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1. Witnessing a murder. 2. Death of a loved one. 3. A fire that destroyed the client's home. 4. A recent rape episode experienced by the client.

3

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Asking the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the lient to stop monopolizing in a frm but compassionate manner. 4. Thank the client for their input, but inform the client that others now need a chance to contribute.

4

A client diagnosed with delirium becomes disoriented & confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurse's station. 2. Use an indirect light source & turn off the television. 3. Keep the television & a soft light on during the night. 4. Play soft music during the night, & maintain a well-lit room.

2

The nurse in the ED is 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. How should the nurse interpret these behaviors? 1. Signs of depression. 2. Reaction to a devastating event. 3. Evidence that the client is a high suicide risk. 4. INdicative of the need for hospital admission.

2

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety. 2. Identifying anxiety-producing situations. 3. Continuing contact with a crisis counselor. 4. Eliminating all anxiety from daily situations.

2

A client diagnosed with terminal cancer 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 response by the nurse is therapeutic? 1. Have you shared your feelings with your family? 2. I think we should talk more about your anger with your family. 3. You're feeling angry that your family continues to hope for you to be cured? 4. You are probably very depressed, which is understandable with such diagnosis.

3

A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for the past week. 2. Client complains of not being able to "do anything" anymore. 3. Client arrives at the clinic neat and appropriate in appearance. 4. Client reports sleeping 12hrs per night and 3-4hrs during the day.

3

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1. I see. 2. Really? 3. You've having difficulty sleeping? 4. Sometimes I have trouble sleeping too.

3

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing goes right for me." Which response by the nurse demonstrates therapeutic communication? 1. You have everything to live for. 2. Why do you see yourself as a failure? 3. Feeling like this is all part of being depressed. 4. You've been feeling like a failure for awhile?

4

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? 1. Have you talked to your family about this? 2. Everyone feeling this way when they are depressed. 3. You will feel better once your medication begins to work. 4. You sound very upset. Are you thinking of hurting yourself?

4

The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client- focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function. 2. Exploring the client's potential for self-harm. 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful. 4. Inquiring about and examining the client's feelings for any that may block adaptive coping.

4