Mental Health Exam 1 practice question

A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client maybe suffering from anorexia nervosa?

"I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls.

Which statement should indicate to a nurse that an individual is experiencing a delusion?

"There's an alien growing in my liver."

.A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response?

"You told me you got fired from your last job for missing too many days after taking drugs all night."

When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority?

Client's safety needs

A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?

Command hallucinations; warn the psychiatrist

A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?

Coronary artery spasm

A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?

Diaphoresis, tremors, and nervousness

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply?

Focus on the feelings generated by the hallucinations and present reality

Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal?

Heart rate of 120 to 140 beats/minute

During postprandial monitoring, a female client with bulimia nervosa tells the nurse,"You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response?

I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?

Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal

A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time?

Placing the client on one-to-one observation while continuing to monitor suicidal ideations

A 24-year old client with anorexia nervosa tells the nurse, "When I look in the mirror,I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings?

Provide objective data and feedback regarding the client's weight

A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time?

Providing a quiet environment and administering medication as needed and prescribed

Nurse Helen is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client?

Providing one-on-one supervision during meals and for 1 hour afterward

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of:

Risk for violence: Self-directed related to impulsive mutilating acts

Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

Set up a strict eating plan for the client

A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia?

Tell me how you feel about the accident."

A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8′′ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care?

Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy

A client diagnosed with schizophrenia tells a nurse, The Shopatouliens took my shoes out of my room last night. Which is an appropriate charting entry to describe this client's statement?

The client is expressing a neologism

For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority?

The client will establish adequate daily nutritional intake

A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

The client will work with the nurse to remain safe

Kellan, a high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome?

The student accepts a referral to a substance abuse counselor

A 16-year-old client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client's parents ask the nurse, "Where do the voices come from?" Which is the appropriate nursing reply?

Your child has a chemical imbalance in the brain which leads of altered thoughts."

Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level?

acetylcysteine (Mucomyst)

Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect:

alcohol withdrawal

Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with:

antisocial personality disorder

A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to:

begin anytime within the next 1 to 2 days

A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, Nurse Mary should

check the client frequently throughout the night

A client whose husband just left her has a recurrence of anorexia nervosa. Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to:

gain control of one part of her life

Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

identify anxiety-causing situations

A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, nurse Tair should plan to:

monitor vital signs, serum electrolyte levels, and acid-base balance

A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is:

total abstinence