Mental Health-NCLEX Questions

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The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further assessment on a priority basis? 1."I check my weight every day without fail." 2."I've been told that I am 10% below ideal body weight." 3."I exercise 3 to 4 hours every day to keep my slim figure." 4."My best friend was in the hospital with this disease a year ago."

3."I exercise 3 to 4 hours every day to keep my slim figure."

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of post-traumatic stress disorder? 1."I'm always crying." 2."I'm afraid to go outside." 3."I keep reliving the abuse." 4."I keep washing my hands over and over."

3."I keep reliving the abuse."

The nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action? 1.Refer the client to a psychiatrist. 2.Encourage the client to move and use the arm. 3.Assess the client for organic causes of the paralysis. 4.Encourage the client to talk about his or her feelings.

3.Assess the client for organic causes of the paralysis.

To create a safe environment for the client diagnosed with major depression with psychotic features, the nurse most importantly devises a plan of care that deals specifically with which problem? 1.Nutrition 2.Self-care needs 3.Disturbed thinking 4.Medication compliance

3.Disturbed thinking

The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT) to treat depression. Which medical diagnosis, if noted on the client's record, would indicate a need to contact the psychiatrist scheduled to perform the ECT? 1.Type 2 diabetes mellitus 2.Peripheral vascular disease 3.Recent myocardial infarction 4.Newly diagnosed hyperthyroidism

3.Recent myocardial infarction

The nurse is developing a plan of care for a client with depression who is scheduled to have electroconvulsive therapy. Which problem is a priority for this client? 1.Fear 2.Anxiety 3.Risk for aspiration 4.Distorted body image

3.Risk for aspiration

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? 1."Why do you believe your roommate would steal from you?" 2."I'll see if I can arrange for you to move in with a different roommate." 3."Tell me more about your belief that your roommate would steal from you." 4."I hear what you are saying, but I have no reason to believe your roommate steals."

4."I hear what you are saying, but I have no reason to believe your roommate steals."

The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1."This form of therapy can be applied to new situations." 2."An advantage of this technique is that change is likely to last." 3."Talking to oneself is a basic component of this form of therapy." 4."It provides a negative reinforcement when the stimulus is produced."

4."It provides a negative reinforcement when the stimulus is produced."

During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries? 1."Thank you, the perfume was a gift." 2."Your comment is really inappropriate." 3."Neither my hair nor my perfume is the focus of today's session." 4."The focus of today's session is on your issues, so let's get started."

4."The focus of today's session is on your issues, so let's get started."

A client diagnosed with schizophrenia is taking haloperidol. The nurse understands that this medication will exert its therapeutic effect through which mechanism? 1.Blocking serotonin reuptake 2.Inhibiting the breakdown of released acetylcholine 3.Blocking the uptake of norepinephrine and serotonin 4.Blocking dopamine from binding to postsynaptic receptors in the brain

4.Blocking dopamine from binding to postsynaptic receptors in the brain

The nurse notes documentation that a newly admitted client experiences flashbacks. What diagnosis would this notation support? 1.Anxiety 2.Agoraphobia 3.Schizophrenia 4.Post-traumatic stress disorder

4.Post-traumatic stress disorder

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? 1.Hypertension 2.Hyperlipidemia 3.Substance abuse disorder 4.Post-traumatic stress disorder

4.Post-traumatic stress disorder

A client diagnosed with depression is not eating adequately and at times even refuses to eat at all. What should the nurse plan to do to meet the client's nutritional needs? 1.Force foods and fluids. 2.Restrict social activities until food intake is increased. 3.Promptly provide snacks and meals when the client requests them. 4.Provide small, frequent meals that include the client's food preferences.

4.Provide small, frequent meals that include the client's food preferences.

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit should expect to note which behaviors in the client? 1.Sad and tearful 2.Suspicious and hostile 3.Frightened and delusional 4.Rigidness in thought and inflexibility

4.Rigidness in thought and inflexibility

An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client? 1.Isolating self 2.Inability to cope 3.Low self-esteem 4.Risk for self-harm

4.Risk for self-harm

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1.Ask 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 client to stop monopolizing in a firm but compassionate manner. 4.Thank the client for the input, but inform the client that others now need a chance to contribute.

4.Thank the client for the input, but inform the client that others now need a chance to contribute.

Before giving the client the initial dose of disulfiram, what should the psychiatric home health nurse determine? 1.If there is a history of hyperthyroidism 2.When the last full meal was consumed 3.If there is a history of diabetes insipidus 4.When the last alcoholic drink was consumed

4.When the last alcoholic drink was consumed

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1.Platelet count 2.Cholesterol level 3.Blood urea nitrogen 4.White blood cell count

White blood cell count

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1.Chess 2.Writing 3.Ping pong 4.Basketball

Writing

A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? 1.Assess the client's vital signs. 2.Identify the client's activity during the pain. 3.Assess for signs related to a panic disorder. 4.Determine the client's use of relaxation techniques.

1 Assess the client's vital signs.

A client diagnosed with depression is scheduled to receive 3 sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame? 1.1 week after the 3rd treatment session 2.3 weeks after the treatment sessions begin 3.Midway between the 2nd and 3rd treatment session 4.8 weeks after the treatment sessions are completed

1. 1 week after the 3rd treatment session

Which statement made by a severely depressed client requires the nurse's immediate attention? 1."Feeling better really isn't important to me anymore." 2."No one can really understand what I've had to deal with." 3."I really don't like the way that new depression pill makes me feel." 4."I've not been the least bit interested in socializing since my divorce."

1."Feeling better really isn't important to me anymore."

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1."I no longer feel that I deserve the beatings my husband inflicts on me." 2."My attendance at the meetings has helped me see that I provoke my husband's violence." 3."I enjoy attending the meetings because they get me out of the house and away from my husband." 4."I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."

1."I no longer feel that I deserve the beatings my husband inflicts on me."

A client diagnosed with an anxiety disorder is prescribed buspirone orally. The client tells the nurse that it is difficult to swallow the tablets. Which is the best instruction to provide the client? 1.Crush the tablets before taking them. 2.Mix the tablet uncrushed in apple sauce. 3.Purchase the liquid preparation with the next refill. 4.Call the primary health care provider for a change in medication.

1.Crush the tablets before taking them.

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? 1.Dementia 2.Schizophrenia 3.Seizure disorder 4.Obsessive-compulsive disorder

1.Dementia

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. 1.Dental decay 2.Moist, oily skin 3.Loss of tooth enamel 4.Electrolyte imbalances 5.Body weight well below ideal range

1.Dental decay 3.Loss of tooth enamel 4.Electrolyte imbalances

The nurse caring for a client diagnosed with severe depression is planning activities for the client. Which activity would be most appropriate for this client? 1.Drawing 2.Playing checkers 3.Painting by numbers 4.Putting a puzzle together

1.Drawing

Which are the most likely characteristics of a client who abuses alcohol? Select all that apply. 1.Male gender 2.Is not married 3.Abuses drugs as well as alcohol 4.Employed in a minimal wage job 5.History of at least 1 suicide attempt

1.Male gender 3.Abuses drugs as well as alcohol 5.History of at least 1 suicide attempt

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/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.Toxic

Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply. 1.Verbal communication is almost nonexistent. 2.Gross motor skills are impacted by involuntary body movements. 3.The client needs frequent redirection because of short attention span. 4.Interpersonal relationships are negatively impacted because of delusional thoughts. 5.Conversations are difficult to follow because of demonstration of loose associations of thought.

1.Verbal communication is almost nonexistent. 3.The client needs frequent redirection because of short attention span.

A client with depression verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right." Which is the best nursing response? 1.Tell the client that this is not true, that we all have a purpose in life. 2.Identify recent behaviors or accomplishments that demonstrate the client's skills. 3.Reassure the client that the nurse knows how the client is feeling and that things will get better. 4.Remain with the client and sit in silence. This will encourage the client to verbalize feelings.

2 .Identify recent behaviors or accomplishments that demonstrate the client's skills.

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder? 1.Put the client in a supine position. 2.Provide emotional support and reassurance. 3.Withhold all sedative or antianxiety medications. 4.Tell the client to breathe very deeply but more slowly.

2. Provide emotional support and reassurance.

Which assessment finding would be a manifestation associated with dementia? 1.Catatonia 2.Confabulation 3.Presence of ritualistic behaviors 4.Increased display of inhibited behaviors

2.Confabulation

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1.Interrupt the client and weigh her immediately. 2.Interrupt the client and offer to take her for a walk. 3.Allow the client to complete her exercise program. 4.Tell the client that she is not allowed to exercise rigorously.

2.Interrupt the client and offer to take her for a walk.

A client with suspected opioid overdose has received a dose of naloxone hydrochloride. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 mm Hg to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which piece of information? 1.The client may next become suicidal. 2.These are signs of opioid withdrawal. 3.These effects will last only a few moments. 4.The client may otherwise sign out against medical advice.

2.These are signs of opioid withdrawal.

An adolescent has been prescribed an amphetamine to help manage a diagnosis of attention deficient hyperactivity disorder. To best minimize the risk of abuse and/or overdose, the nurse expects that the medication will be administered via which method? 1.Sublingual tablets 2.Transdermal patch 3.Rectal suppository 4.Weekly intramuscular injections

2.Transdermal patch

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

2.Use an indirect light source and turn off the television.

2.Writing

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression? 1.The mother is caring for the infant in a loving manner. 2.The mother demonstrates an interest in the surroundings. 3.The mother constantly complains of tiredness and fatigue. 4.The mother looks forward to visits from the father of the newborn.

3 The mother constantly complains of tiredness and fatigue.

Which interventions should the nurse include in the plan of care for a depressed client involved in cognitive-behavioral therapy? Select all that apply. 1.Assisting the client to identify and test negative cognition 2.Assisting the client to participate in the treatment process 3.Assisting the client to develop alternative thinking patterns 4.Assisting the client to rehearse new cognitive and behavioral responses 5.Assisting the client with the administration of antidepressant medications 6.Assisting the client's family to participate in group therapy on a regular basis

1.Assisting the client to identify and test negative cognition 2.Assisting the client to participate in the treatment process 3.Assisting the client to develop alternative thinking patterns 4.Assisting the client to rehearse new cognitive and behavioral responses

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1.Communicate expected behaviors to the client. 2.Ensure that the client knows that he or she is not in charge of the nursing unit. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 5.Enforce rules by informing the client that he or she will not be allowed to attend therapy groups. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1.Communicate expected behaviors to the client. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1.Verbal communication is almost nonexistent. 3.The client needs frequent redirection because of short attention span.

1Communicate expected behaviors to the client. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

The nurse gathers data from the client who was prescribed buspirone hydrochloride 1 month ago. The nurse interprets that the medication is effective when the client reports an absence of which event? 1.Delusions 2.Severe anxiety 3.Alcohol cravings 4.Paranoid thoughts

2.Severe anxiety

The nurse is creating a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to provide which priority information to the family? 1.Brain anomalies that are responsible for this disorder 2.Signs that indicate the client may be considering suicide 3.The importance benzodiazepines play in the management of this disorder 4.The possibility that the client will experience medication-induced tinnitus

2.Signs that indicate the client may be considering suicide

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 complication? 1.Parkinsonism 2.Tardive dyskinesia 3.Hypertensive crisis 4.Neuroleptic malignant syndrome

2.Tardive dyskinesia

A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) 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 Crackers 5 Tossed Salad

The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1."My medications will help my anxious feelings." 2."I'll go to support group and talk about what I am feeling." 3."When I have command hallucinations, I'll call a friend for help." 4."I need to get enough sleep and eat well to help prevent feeling anxious."

3."When I have command hallucinations, I'll call a friend for help."

Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action? 1.Begin to teach relaxation techniques. 2.Encourage the client to discuss the assault. 3.Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation.

3.Remain with the client until the anxiety decreases.

The mother of a teenage client states that her daughter, diagnosed with an anxiety disorder, "eats nothing but junk food, has never liked going to school, and hangs out with the wrong crowd." What discharge instruction will be most effective in helping the mother to manage her daughter's condition? 1.Restrict the daughter's socializing time with her friends. 2.Keep her daughter out of school until her anxiety is well managed. 3.Restrict the amount of chocolate and caffeine products in the home. 4.Consider taking time off from work to help her daughter learn to manage the anxiety.

3.Restrict the amount of chocolate and caffeine products in the home.

A client diagnosed with bipolar mood disorder has been given a prescription for carbamazepine. The nurse teaching the client about medication side and adverse effects instructs the client to notify the primary health care provider if which symptom develops? 1.Nausea 2.Dizziness 3.Sore throat 4.Drowsiness

3.Sore throat

The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment? 1."I don't think I can do this on my own. I still need help coping with things. I know I need to keep working with staff, even now that I'm going home." 2."This has been the hardest thing I've ever had to deal with. I've made progress in learning how to communicate, especially with my family. It's hard to tell them when I need help." 3."I really tried to listen to what people said in the group sessions. Sometimes it was hard, but I think we really helped each other. I think I've learned it's all right to get disappointed sometimes." 4."I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end."

4."I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end."

The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment? 1."I took an extra pill for anxiety and got through the funeral fairly well." 2."I worry that if I don't take my anxiety pill on time, I'll have one of those attacks." 3."Taking my anxiety pills before I leave has helped me to cross the bridge and go to work every morning." 4."I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."

4."I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1."This form of therapy can be applied to new situations." 2."An advantage of this technique is that change is likely to last." 3."Talking to oneself is a basic component of this form of therapy." 4."This form of therapy provides a negative reinforcement when the stimulus is produced.

4."This form of therapy provides a negative reinforcement when the stimulus is produced.

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 feels 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."You sound very upset. Are you thinking of hurting yourself?"

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. 1."I'm afraid of spiders." 2."I keep reliving the robbery." 3."I see his face everywhere I go." 4."I don't want anything to eat now." 5."I might have died over a few dollars in my pocket." 6."I have to wash my hands over and over again many times."

2."I keep reliving the robbery." 3."I see his face everywhere I go." 5."I might have died over a few dollars in my pocket."

The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client? 1."You look lovely today." 2."You're wearing a new blouse." 3."Don't worry; everyone gets depressed once in a while." 4."You will feel better when your medication starts to work."

2."You're wearing a new blouse."

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques should the nurse use while interacting with the client? Select all that apply. 1.Turn the client's favorite TV show on. 2.Ask the client to identify how he or she feels. 3.Help the client identify the cause of the anxiety. 4.Lean against the wall casually with arms crossed.

2.Ask the client to identify how he or she feels. 3.Help the client identify the cause of the anxiety.

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize which assessment finding as requiring immediate intervention? 1.Grandiose delusions of being a czar of Russia 2.Constant physical activity and poor oral intake 3.Constant, incessant talking, with sexual innuendoes 4.Outlandish behaviors and wearing odd, eccentric clothing

2.Constant physical activity and poor oral intake

The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the medication? 1.Cardiovascular symptoms 2.Gastrointestinal dysfunctions 3.Problems with mouth dryness 4.Problems with excessive sweating

2.Gastrointestinal dysfunctions

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.Identifying anxiety-producing situations

During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor? 1.Apathy 2.Impaired pain perception 3.Distrust of authority figures 4.Poor verbal communication skills

2.Impaired pain perception

The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication? 1.In 2 months 2.In 2 to 3 weeks 3.During the first week 4.During the sixth week of administration

2.In 2 to 3 weeks

The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information should the nurse incorporate in the discussion? 1.Consume a low-fiber diet. 2.Increase fluids and bulk in the diet. 3.Rest if the heart begins to beat rapidly. 4.Walk if you have difficulty urinating because this is a normal side effect.

2.Increase fluids and bulk in the diet.

Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply. 1.Affects males more often than females 2.Is related to abnormal melatonin metabolism 3.Usually results in debilitating symptomatology 4.Improves during the spring and summer months 5.Is a result of alterations in the available amounts of sunlight 6.A craving for carbohydrates lessens during sunnier and spring months

2.Is related to abnormal melatonin metabolism 4.Improves during the spring and summer months 5.Is a result of alterations in the available amounts of sunlight 6.A craving for carbohydrates lessens during sunnier and spring months

The nurse assesses a client with an admitting diagnosis of bipolar affective disorder, mania. Which symptom presented by the client would require the nurse's immediate intervention? 1.Outlandish behaviors and inappropriate dress 2.Nonstop physical activity and poor nutritional intake 3.Grandiose delusions of being a royal descendent of King Arthur 4.Constant, incessant talking that includes sexual innuendoes and teasing the staff

2.Nonstop physical activity and poor nutritional intake

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. 1.Dementia 2.Panic disorder 3.Multiple personality disorder 4.Post-traumatic stress disorder 5.Obsessive-compulsive disorder

2.Panic disorder 4.Post-traumatic stress disorder 5.Obsessive-compulsive disorder

The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking? 1.Provide the client with written instructions regarding the routine of the unit. 2.Present verbal instructions regarding expectations in single, simple commands. 3.Assess the client's understanding of instructions by requiring restatement of expectations. 4.Incorporate family members in determining the emotional and physical needs of the client.

2.Present verbal instructions regarding expectations in single, simple commands.

A client reported to the nurse that he has been taking an extra dose of his tricyclic antidepressant for a week because he has been feeling more depressed than usual. Hearing this, the nurse knows which are the most appropriate actions to take? Select all that apply. 1.Tell the client that taking an extra dose is ok as long as it is not longer than 1 week. 2.Re-educate the client because tricyclic antidepressant overdoses can be life threatening. 3.Advise the client to take in more liquids while an extra dose is being taken because dry mouth is a side effect of this medication. 4.Tell the client to continue taking the extra dose; the client knows how he is feeling and can stop the extra dose when he is feeling more himself. 5.Inform the client that if he experiences any symptoms of dysrhythmias, dry mouth, confusion, agitation, or hallucinations, he should seek medical attention right away.

2.Re-educate the client because tricyclic antidepressant overdoses can be life threatening. 5.Inform the client that if he experiences any symptoms of dysrhythmias, dry mouth, confusion, agitation, or hallucinations, he should seek medical attention right away.

During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior? 1.An unreasonable fear of something 2.Repetitive actions to manage anxiety 3.Misinterpretation of common events 4.Recurring thoughts that are intrusive

2.Repetitive actions to manage anxiety

A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1.Constipation 2.Seizure activity 3.Increased weight 4.Dizziness when getting upright

2.Seizure activity

A client diagnosed with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse? 1."Where is she? I'll talk to her." 2."I can see no Grand Duchess. You will need to trust me on that." 3."You will be safe here. Your thinking will be clearer after your medication starts to work." 4."The Grand Duchess, huh? Well, I'm the Queen, and I will order her to stay away from you."

3."You will be safe here. Your thinking will be clearer after your medication starts to work."

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 12 hours per night and 3 to 4 hours during the day.

3.Client arrives at the clinic neat and appropriate in appearance.

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking 2 packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury? 1.Developing lung cancer and/or other respiratory disorders 2.Withdrawal symptoms triggering a stress-induced relapse 3.Diminishing the effectiveness of psychotropic medication 4.Developing gastrointestinal disorders, including bleeding ulcers

3.Diminishing the effectiveness of psychotropic medication

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? 1.Reassure the client that things will get better. 2.Tell the client that this is not true and that we all have a purpose in life. 3.Identify recent behaviors or accomplishments that demonstrate the client's skills. 4.Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

3.Identify recent behaviors or accomplishments that demonstrate the client's skills.

The nurse caring for a client with a diagnosis of acute schizophrenia should use which approach when planning care? 1.Allow the client to set the goals for the plan of care. 2.Let the client act out initially, and use the quiet room and restraints as needed. 3.Provide assistance with grooming and nutrition until the client's thinking has cleared. 4.Repeatedly point out inconsistencies in the client's communication during initial treatment.

3.Provide assistance with grooming and nutrition until the client's thinking has cleared.

The nurse is preparing a client with schizophrenia with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1."My medications will help my anxious feelings." 2."I'll go to support group and talk about what I am feeling." 3."I need to get enough sleep and eat well to help prevent feeling anxious." 4."When I have command hallucinations, I'll call a friend and ask him what I should do."

4."When I have command hallucinations, I'll call a friend and ask him what I should do."

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression? 1.Restrict the client smoking for 12 hours. 2.Enforce nothing by mouth (NPO) status for 16 hours. 3.Limit the client's participation in unit activities for 24 hours. 4.Assure that an electrocardiogram is performed within 24 hours.

4.Assure that an electrocardiogram is performed within 24 hours.

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia? 1.Abnormally high blood flow to the frontal lobes 2.Atrophy of both the limbic structures and cerebellum 3.Abnormally small fissures on the surface of the brain 4.Atrophy of the lateral and/or third ventricles of the brain

4.Atrophy of the lateral and/or third ventricles of the brain

Which activity should the nurse include in the plan of care for a client with mania who is experiencing psychomotor agitation? 1.Playing checkers with members of the staff 2.Reading in a quiet, low-stimulus environment 3.Engaging in a card game with other clients on the unit 4.Attending a clay-molding class that is scheduled for today

4.Attending a clay-molding class that is scheduled for today

A client is brought into the emergency department for suspected tricyclic antidepressant overdose. Place the actions that the nurse should take in order of priority. All options must be used. Select the correct sequence number for each item. 1.Administer oxygen.2.Check and monitor vital signs.3.Obtain an electrocardiogram.4.Check airway and maintain patency.5.Prepare gastric lavage with activated charcoal.6.Prepare to administer prescribed medications.

4.Check airway and maintain patency. 1.Administer oxygen. 2.Check and monitor vital signs. 3.Obtain an electrocardiogram. 5.Prepare gastric lavage with activated charcoal. 6.Prepare to administer prescribed medications.

A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1.Complaints of insomnia 2.Complaints of hunger and fatigue 3.A pulse rate less than 60 beats per minute 4.Frequent hand washing with hot, soapy water

4.Frequent hand washing with hot, soapy water

A client diagnosed with depression and prescribed tranylcypromine sulfate has been instructed on the appropriate diet. The nurse determines that the client understands the diet if which foods are selected from the dietary menu? 1.Pickled herring, french fries, and milk 2.Pepperoni pizza, salad, and a cola drink 3.Roasted chicken, roasted potatoes, and beer 4.Fried haddock, baked potato, and a cola drink

4.Fried haddock, baked potato, and a cola drink

When planning the discharge of a client with chronic anxiety, 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.Identifying anxiety-producing situations

The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention? 1.Including the client's support system in the teaching 2.Facilitating weekly maintenance therapy for the client 3.Having the client restate discharge goals and strategies 4.Stressing the importance of client compliance with the medication plan

1.Including the client's support system in the teaching

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? 1.Tearful, self-isolated 2.Affect bland, withdrawn 3.Fist clenched, pounding table, fearful 4.Temperature 98.4º F (36.8º C); respirations 18 breaths/min

3.Fist clenched, pounding table, fearful

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1.Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 4.Provide stimulation in the environment. 5.Provide reality orientation as appropriate. 6.Maintain NPO (nothing by mouth) status.

1.Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 5.Provide reality orientation as appropriate.

The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply. 1.Ask permission before touching the client. 2.Provide a warm, social approach to the client. 3.Eliminate all unnecessary physical contact with the client. 4.Defuse any anger or verbal attacks with a nondefensive stance. 5.Use simple and clear language when communicating with the client.

1.Ask permission before touching the client. 3.Eliminate all unnecessary physical contact with the client. 4.Defuse any anger or verbal attacks with a nondefensive stance. 5.Use simple and clear language when communicating with the client.

The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs? 1.Flashbacks 2.Amotivational syndrome 3.Enhanced physical strength 4.Absence of pain perception

1.Flashbacks

Which roommate choice is least appropriate for a client diagnosed with anorexia nervosa who is in a state of starvation? 1.A client with pneumonia 2.A client who had back surgery 3.A client with a fractured pelvis 4.A client who has had a myocardial infarction

1.A client with pneumonia

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? 1.Admitting to having a problem 2.Substituting other activities for gambling 3.Stating that the gambling will be stopped 4.Discontinuing relationships with people who gamble

1.Admitting to having a problem

The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. 1.Have the client void. 2.Obtain an informed consent. 3.Administer tap water enemas. 4.Avoid discussing the procedure. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours.

1.Have the client void. 2.Obtain an informed consent. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours.

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply. 1.A birthday of March 30 2.A loss of interest in hobbies 3.A suicide attempt 6 months ago 4.Adopted by family at age 14 months 5.Brain scan shows increased blood flow to the frontal lobes 6.Magnetic resonance imaging shows temporal lobe atrophy

1.A birthday of March 30 2.A loss of interest in hobbies 3.A suicide attempt 6 months ago 6.Magnetic resonance imaging shows temporal lobe atrophy

The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply. 1.Assist the client in selecting foods from the food menu. 2.Offer high-calorie fluids throughout the day and evening. 3.Allow the client to eat alone in the room if the client requests to do so. 4.Offer small high-calorie, high-protein snacks during the day and evening. 5.Select the foods for the client to be sure that the client eats a balanced diet.

1.Assist the client in selecting foods from the food menu. 2.Offer high-calorie fluids throughout the day and evening. 4.Offer small high-calorie, high-protein snacks during the day and evening.

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1.Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive

1.Avoidant

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. Which action should the nurse take at this time? 1.Call the nursing supervisor. 2.Call security to block the exits to the nursing unit. 3.Restrain the client, and call the primary health care provider. 4.Tell the client that readmission is not possible after leaving against medical advice.

1.Call the nursing supervisor.

A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1.Call the nursing supervisor. 2.Call security to block all exit areas. 3.Restrain the client until the primary health care provider (PHCP) can be reached. 4.Tell the client that the client cannot return to this hospital again if the client leaves now.

1.Call the nursing supervisor.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1.Communicate expected behaviors to the client. 2.Ensure that the client knows that they are not in charge of the nursing unit. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 5.Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? 1.During the entire family visit, the client presented with an expressionless, blank look. 2.The client demonstrated minimal response to the news that his discharge had been postponed. 3.The client grimaced during the entire therapy session that focused on finding one's personal joy. 4.During grief therapy, the client was observed laughing while another client described the death of a parent.

1.During the entire family visit, the client presented with an expressionless, blank look.

Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply. 1.Electrolyte levels 2.Exercise patterns 3.Intake and output 4.Pupillary response 5.Elimination patterns 6.Deep tendon reflexes

1.Electrolyte levels 3.Intake and output 5.Elimination patterns

An older client diagnosed with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to minimize the client's risk for injury? 1.Turn off the television and radio, and use a night-light. 2.Keep soft lighting and the television on during the night. 3.Change the client's room to one nearer the nurses' station. 4.Play soft instrumental music all night, and do not turn down the lights.

1.Turn off the television and radio, and use a night-light.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? 1.Use of confabulation 2.Improvement in sleeping 3.Absence of sundown syndrome 4.Presence of personal hygienic care

1.Use of confabulation

When assessing a client for a possible physical dependency on alcohol, the nurse should ask which priority question? 1."Are you drinking more than you did 5 years ago?" 2."How do you feel when you haven't had a drink all day?" 3."Does your drinking ever cause you problems with your family?" 4."Do you ever feel that you really need a drink to calm your nerves?"

2."How do you feel when you haven't had a drink all day?"

What statement should the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety? 1."Try not to worry so much." 2."I can see that you are becoming upset." 3."Everything is going to be all right; just relax." 4."Why are you having trouble controlling your anxiety?"

2."I can see that you are becoming upset."

The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to stop using drugs." Which response by the nurse would be therapeutic? 1."You have said this many times before!" 2."Tell me what makes you feel that you are ready." 3."I'm so glad to hear you talking this way. I will let your psychiatrist know." 4."I need to see changes in you to believe that you are ready to stop using drugs."

2."Tell me what makes you feel that you are ready."

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? 1."Why don't you tell your spouse about this?" 2."What do you find difficult about this situation?" 3."This is not the best time to make that decision." 4."I agree with you. You should get out of this situation."

2."What do you find difficult about this situation?"

The client diagnosed with depression says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse best assesses the client's nutritional issue? 1."The last few weeks?" 2."You haven't had an appetite at all?" 3."Have patience; it will take time for your appetite to improve." 4."When the medication begins to work, your appetite will return."

2."You haven't had an appetite at all?"

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1.A client with pneumonia 2.A client undergoing diagnostic tests 3.A client who thrives on managing others 4.A client who could benefit from the client's assistance at mealtime

2.A client undergoing diagnostic tests

The mother of a child diagnosed with attention deficit hyperactivity disorder has been given instructions about how to administer methylphenidate. Which response by the mother shows she understands the information about the best way to administer the medication? 1.At bedtime 2.After breakfast 3.At the evening meal 4.With a bedtime snack

2.After breakfast

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1.Ask the client why he started taking illegal drugs. 2.Ask the client about the amount of drug use and its effect. 3.Ask the client how long he thought that he could take drugs without someone finding out. 4.Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

2.Ask the client about the amount of drug use and its effect.

Which behavior demonstrated by a client diagnosed with depression indicates a need for suicide precautions? 1.Refuses to attend group therapy 2.Asks about how to get a will notarized 3.Argues with family members during visiting hours 4.Becomes easily agitated when roommate changes the television channel

2.Asks about how to get a will notarized

When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration? 1.Encouraging social interactions 2.Assessing all activities for safety risks 3.Focus upon providing verbal stimulation 4.Providing detailed instructions to ensure success

2.Assessing all activities for safety risks

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? 1.Increase socialization of the client with peers. 2.Avoid using a whisper voice in front of the client. 3.Begin to educate the client about social supports in the community. 4.Have the client sign a release of information to appropriate parties for assessment purposes.

2.Avoid using a whisper voice in front of the client.

The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers? 1.Barbiturate use commonly results in a rush of energy. 2.Barbiturate abuse is the cause of many drug overdose deaths. 3.The primary outcome of barbiturate abuse is psychological dependency. 4.A dangerous increase in blood pressure (BP) occurs with barbiturate abuse.

2.Barbiturate abuse is the cause of many drug overdose deaths.

The nurse is working with a client who shows signs of benzodiazepine withdrawal. The nurse should suspect that the client has suddenly discontinued taking which prescribed medication? 1.Sertraline 2.Diazepam 3.Fluoxetine 4.Haloperidol

2.Diazepam

The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed? 1.Clonidine 2.Disulfiram 3.Pyridoxine hydrochloride 4.Chlordiazepoxide hydrochloride

2.Disulfiram

Buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse plans to include which teaching point when reviewing this medication with the client? 1.The medication is addicting. 2.Dizziness and nervousness may occur. 3.Tolerance can develop with this medication. 4.The medication can produce a sedating effect

2.Dizziness and nervousness may occur.

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1.Normal behavior 2.Evidence of the client's disturbed body image 3.Regression as the client is moving toward the community 4.Indicative of the client's ambivalence about hospital discharge

2.Evidence of the client's disturbed body image

The nurse is preparing to create a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse should plan to include which component as a priority in the plan of care? 1.The medical diagnosis of the client 2.Individualized goals and objectives 3.Attendance at group therapy sessions 4.Self-care measures to improve hygiene

2.Individualized goals and objectives

The psychiatric home care nurse visits a client diagnosed with a phobia that triggers panic attacks. When teaching the client to use paradoxical intention, which intervention will the nurse demonstrate? 1.Having the client confront the anxiety-provoking stimulus and providing support during the episode 2.Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor 3.Presenting the anxiety-provoking stimulus without any preparation of the client and having him or her remain exposed until the anxiety subsides 4.Using progressive relaxation toward the client's individual anxiety hierarchy, increasing the level of difficulty, and pairing relaxation with the gradual exposure to reduce his or her anxiety

2.Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor

A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor? 1.Development of tolerance for the drug 2.Lack of naturally occurring endorphins 3.Client's psychological dependency on opiates 4.Typical abuse pattern for central nervous system depressants

2.Lack of naturally occurring endorphins

The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action? 1.Engaging in self-mutilating acts 2.Observing rigid rules and regulations 3.Always reverting to the independent role 4.Constantly striving to avoid making decisions

2.Observing rigid rules and regulations

A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective? 1."I'll eat until I don't feel hungry." 2."I no longer have a weight problem." 3."I don't want to starve myself anymore." 4."My friends and I went out to lunch today."

4."My friends and I went out to lunch today."

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.Rapid heartbeat or anxiety

The nurse taking a medication history for a client who has been admitted to the nursing unit notes that the client is receiving olanzapine. The nurse interprets that this client most likely has a history of which disorder? 1.Hypertension 2.Schizophrenia 3.Diabetes mellitus 4.Diabetes insipidus

2.Schizophrenia

A client diagnosed with schizophrenia has been prescribed clozapine. The nurse should monitor the client for which side/adverse effects of this medication? Select all that apply. 1.Diarrhea 2.Sedation 3.Dry mouth 4.Weight loss 5.Orthostatic hypotension 6.Presence of a fixed stare

2.Sedation 3.Dry mouth 5.Orthostatic hypotension 6.Presence of a fixed stare

The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms? 1.The danger time has passed. 2.Signs may appear at any time. 3.The next hour could be critical. 4.Withdrawal has likely already started.

2.Signs may appear at any time.

A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis? 1.Depression 2.Somatization disorder 3.Post-traumatic stress disorder 4.Obsessive-compulsive disorder

2.Somatization disorder

Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? 1.The client remains in the same physical position for hours. 2.The client is convinced that the curtains are actually ghosts. 3.The client looks for a cat when someone says, "It's raining cats and dogs." 4.The client repeatedly asks, "Can you see my dead sister over by the door?

2.The client is convinced that the curtains are actually ghosts.

A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on? 1.The object of the crisis 2.The client's physical condition 3.The client's coping mechanisms 4.The presence of support systems

2.The client's physical condition

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational 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.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client

2.The death of a loved one

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1."If it's any help, everyone is nervous before surgery." 2."I will be happy to explain the entire surgical procedure to you." 3."Can you share with me what you've been told about your surgery?" 4."Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3."Can you share with me what you've been told about your surgery?"

An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the nurse would be therapeutic? 1."You think AA is for fanatics?" 2."It sounds as if you look for any reason to drink!" 3."Not any 1 strategy for remaining sober is best for everyone." 4."I agree. AA is definitely not for you if you find it is a trigger to drink."

3."Not any 1 strategy for remaining sober is best for everyone."

A client diagnosed with depression shares with the outpatient clinic nurse, "I lost my job this week and can't pay my rent. My daughter is my only family, but I don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern? 1."Let's talk about the circumstances that caused you to lose your job." 2."There are homeless shelters available for people who are experiencing this exact situation." 3."Wouldn't you want to know if your daughter was having difficulties so you could help if you could?" 4."Being homeless would allow us to admit you to the hospital so you will have a place to eat and sleep."

3."Wouldn't you want to know if your daughter was having difficulties so you could help if you could?"

3."You will be safe here. Your thinking will be clearer after your medication starts to work."

Which behavior would the nurse anticipate a client diagnosed with nyctophobia to demonstrate? 1.Declines an invitation to walk around the park 2.Never takes an elevator but rather climbs the stairs 3.Always turns on the overhead light before entering a darkened room 4.Refuses to engage in conversations when in the presence of more than 2 to 3 people

3.Always turns on the overhead light before entering a darkened room

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1.Call security. 2.Call the police. 3.Call the nursing supervisor. 4.Lock the coworker in the medication room until help is obtained.

3.Call the nursing supervisor.

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition? 1.Psychosis 2.Repression 3.Conversion disorder 4.Dissociative disorder

3.Conversion disorder

Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety? 1.Believes the attacker is in the emergency department 2.Detached, requiring gentle probing to respond to questions 3.Is pacing while describing the situation using a rapid speech pattern 4.Talks about being "panic stricken" that something else "bad" will happen

3.Is pacing while describing the situation using a rapid speech pattern

At what time of day does the nurse recommend that a child prescribed methylphenidate be given the last dose of the day of the medication? 1.At bedtime 2.With a bedtime snack 3.Just before the noontime meal 4.In the morning, 2 hours before breakfast

3.Just before the noontime meal

The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1.Anxiety 2.Unrealistic outlook 3.Lack of ability to cope effectively 4.Disturbances in thoughts and ideas

3.Lack of ability to cope effectively

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation? 1.Trusting the staff 2.Socializing with other clients at a holiday party 3.Making decisions about living arrangements after discharge 4.Identifying ways to minimize the tendency to be self-centered

3.Making decisions about living arrangements after discharge

A client diagnosed with anxiety is starting therapy with lorazepam. Which factor in the client's history should prompt the nurse to consult with the primary health care provider before administering the medication? 1.Hypothyroidism 2.Diabetes mellitus 3.Narrow-angle glaucoma 4.Coronary artery disease

3.Narrow-angle glaucoma

The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal? 1.Constipation, insomnia, and hallucinations 2.Staggering gait, slurred speech, and violent outbursts 3.Nausea, vomiting, diarrhea, muscle aches, and diaphoresis 4.Decreased heart rate and blood pressure, and dry nose, mouth, and skin

3.Nausea, vomiting, diarrhea, muscle aches, and diaphoresis

The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse should anticipate that the client has changes in which component of the nervous system? 1.Glia 2.Peripheral nerves 3.Neuronal dendrites 4.Monoamine oxidase

3.Neuronal dendrites

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1.Engaging in immoral acts 2.Always reinforcing self-approval 3.Observing rigid rules and regulations 4.Having the need always to make the right decision

3.Observing rigid rules and regulations

3.Restrict the amount of chocolate and caffeine products in the home.

The nurse is creating a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care? 1.Promote complete independence in the client. 2.Strengthen the client's ability to manage stress. 3.Reward the client when a desired behavior is performed. 4.Provide consistent negative reinforcement to promote appropriate behaviors.

3.Reward the client when a desired behavior is performed.

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? 1.Ask direct questions to encourage talking. 2.Leave the client alone so as to minimize external stimuli. 3.Sit beside the client in silence with simple open-ended questions. 4.Take the client into the dayroom with other clients to provide stimulation.

3.Sit beside the client in silence with simple open-ended questions.

The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? 1.Depression 2.Schizophrenia 3.Somatization disorder 4.Obsessive-compulsive disorder

3.Somatization disorder

Which is a primary behavior of a client diagnosed with antisocial personality disorder? 1.Frequently expresses suicidal ideations 2.Leaves the dayroom when anyone else enters 3.Will take personal items from other clients' rooms 4.Requires constant reassurance whenever required to make a decision

3.Will take personal items from other clients' rooms

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider prescribes an enteral tube feeding of a standard formula to run at 40 mL/hr. A nursing student is assigned to care for the client, and the nursing instructor asks the student to describe the nursing considerations related to a tube feeding. Which statement, if made by the student, indicates an understanding of this dietary treatment? 1."Enteral tube feedings frequently cause sepsis." 2."Enteral feedings should be refrigerated until just before use." 3."The caloric value of enteral feedings is generally 5 to 10 calories per milliliter." 4."Enteral feedings require the normal digestive capabilities of the gastrointestinal tract."

4."Enteral feedings require the normal digestive capabilities of the gastrointestinal tract."

A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement supports the existence of an alcohol tolerance problem? 1."I've never drunk so much that I've passed out." 2."I'm just a social drinker. I seldom drink when I'm alone." 3."I don't have to drink to feel good. I drink because I like the way it tastes." 4."I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep."

4."I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep."

When planning discharge care for a client diagnosed with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement? 1."I hope I am going to like my new counselor." 2."I sure hope I will still be productive at work." 3."I am going to keep a close check on any stress I have in my life." 4."I will take the medicine until I am sure I can handle my own problems."

4."I will take the medicine until I am sure I can handle my own problems."

The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic? 1."Does anyone in the group want to respond to that?" 2."So you only call him in sick because you are worried about money?" 3."Hasn't the group discussed this before? What conclusion did you all come to?" 4."It is a difficult situation, but do you agree that enabling creates codependency?"

4."It is a difficult situation, but do you agree that enabling creates codependency?"

A client diagnosed with a borderline personality disorder says to the nurse, "Sometimes I do things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the most appropriate nursing response? 1."Next time, pick less dangerous and expensive ways to explode." 2."What can you do to stop your behavior when it gets to that point the next time?" 3."It's a good thing that you don't abuse substances, or you might be dead because of your recklessness." 4."It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."

4."It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? 1."Inner voices tell me to perform my rituals." 2."My behavior is a conscious attempt to punish myself." 3."I'm demonstrating control when I engage in my rituals." 4."My rituals are ways for me to control unpleasant thoughts or feelings."

4."My rituals are ways for me to control unpleasant thoughts or feelings."

A heroin-addicted client who is taking methadone hydrochloride discontinues the methadone without consulting the primary health care provider. The client says to the nurse, "I thought I didn't need the methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything." Which statement by the nurse is therapeutic? 1."It sounds as if everything you do is either all or nothing." 2."Talk to your counselor; maybe everything isn't ruined yet." 3."You will need to restart your recovery starting from the beginning." 4."We need to prepare you to recognize those things that trigger you to relapse."

4."We need to prepare you to recognize those things that trigger you to relapse."

4.Assure that an electrocardiogram is performed within 24 hours.

4.Attending a clay-molding class that is scheduled for today

In formulating a discharge teaching plan, the nurse should include which precaution for a client with bipolar disorder who is prescribed lithium carbonate therapy? 1.Avoid soy sauce, wine, and aged cheese. 2.Have the blood lithium level checked every 2 weeks. 3.Take the medication only as prescribed to avoid becoming addicted. 4.Check with the psychiatrist before using any over-the-counter medications.

4.Check with the psychiatrist before using any over-the-counter medications.

The nurse is reviewing the medical record of a hospitalized client who received electroconvulsive therapy (ECT) 3 years ago for the treatment of depression. Which assessment data would support that the therapy resulted in retrograde amnesia in the client? 1.The staff needs to frequently reorient the client to the rules of this current unit. 2.The client has demonstrated difficulty remembering the address of the family's new home. 3.The medical record states that the client experienced memory loss for 2 days after the ECT treatment. 4.During the admission interview, the client can't remember why the ECT treatment was originally prescribed.

4.During the admission interview, the client can't remember why the ECT treatment was originally prescribed.

During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia? 1.Refusing to eat and excessive exercising 2.Eating only vegetables and fruits and fasting 3.Hoarding of food and difficulty controlling food intake 4.Eating a lot of food in a short period of time and misuse of laxatives

4.Eating a lot of food in a short period of time and misuse of laxatives

A client in a manic state presents to the dayroom only partially dressed and is making sexual remarks and gestures toward the staff and other clients. Which is the initial nursing action? 1.Instruct the client to go back to his room. 2.Inform the client that such behavior will not be accepted. 3.Instruct the other clients to go to their rooms immediately. 4.Escort the client to his room to get appropriately dressed.

4.Escort the client to his room to get appropriately dressed.

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. What is the nurse's priority in the plan of care? 1.Monitor for repetitive behavior. 2.Demand active participation in care. 3.Educate the client about self-care needs. 4.Establish a trusting nurse-client relationship.

4.Establish a trusting nurse-client relationship.

A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for? 1.Coarse hand tremor, agitation, hallucinations, and hypotension 2.Hypotension, ataxia, muscular rigidity, and tactile hallucinations 3.Hypotension, stupor, agitation, headache, and auditory hallucinations 4.Fever, hypertension, changes in level of consciousness, and hallucinations

4.Fever, hypertension, changes in level of consciousness, and hallucinations

4.Fried haddock, baked potato, and a cola drink

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? 1.Providing a supportive environment 2.Examining intrapsychic conflicts and past issues 3.Emphasizing social interaction with clients who withdraw 4.Helping the client to examine dysfunctional thoughts and beliefs

4.Helping the client to examine dysfunctional thoughts and beliefs

The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1.Hypotension, ataxia, hunger 2.Stupor, lethargy, muscular rigidity 3.Hypotension, coarse hand tremors, lethargy 4.Hypertension, changes in level of consciousness, hallucinations

4.Hypertension, changes in level of consciousness, hallucinations

The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction? 1.Emboli 2.Hypotension 3.Thrombophlebitis 4.Impaired wound healing

4.Impaired wound healing

The nurse finds a client recently admitted with a diagnosis of anorexia nervosa engaged in a strenuous exercise routine. Which action should be the priority? 1.Interrupt the client, and offer to take her for a walk. 2.Allow the client to complete her exercise program. 3.Ignore the behavior, and return when the client is finished. 4.Tell the client that she is not allowed to exercise rigorously.

4.Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis

The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal? 1.Increased appetite, irritability, anxiety, restlessness, and altered concentration 2.Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor 3.Depression, high drug craving, fatigue, altered sleep patterns, hypertension, agitation, and paranoia 4.Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis

4.Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.Headache and tachypnea 2.Hyperactivity and dyspnea 3.Muscle twitches and cyanosis 4.Lightheadedness and paresthesias

4.Lightheadedness and paresthesias

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1.Incessant talking and sexual innuendoes 2.Grandiose delusions and poor concentration 3.Outlandish behaviors and inappropriate dress 4.Nonstop physical activity and poor nutritional intake

4.Nonstop physical activity and poor nutritional intake

The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care? 1.Disrupted appearance because of weight 2.Inability to feed self because of weakness 3.Pain because of an inflamed gastric mucosa 4.Nutritional imbalance because of lack of intake

4.Nutritional imbalance because of lack of intake

A client diagnosed with depression is prescribed amitriptyline hydrochloride. During the initial phases of treatment, the client's care plan should include which nursing intervention? 1.Obtain daily drug blood levels. 2.Provide the client a tyramine-free diet. 3.Assess the client for anticholinergic effects. 4.Obtain postural blood pressure prior to each medication administration.

4.Obtain postural blood pressure prior to each medication administration.

The primary health care provider is planning to prescribe a medication for a client with major depression. Which medication should the nurse expect to be prescribed? 1.Diazepam 2.Lorazepam 3.Phenobarbital 4.Paroxetine hydrochloride

4.Paroxetine hydrochloride

When discussing an individual's tendency to substance abuse, the nurse should identify which assessment data as a primary biological factor? 1.The client is a 25-year-old male. 2.The client is employed as a firefighter. 3.The client is of German ethnic background. 4.The client has 2 family members who have abused.

4.The client has 2 family members who have abused.

What information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia? 1.Their child will very likely experience difficulty in school. 2.The prognosis for their child is good because he is so young. 3.With medication, their child is not likely to experience relapses. 4.Their child will be treated for an imbalance of the chemical dopamine.

4.Their child will be treated for an imbalance of the chemical dopamine.

Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication? 1.Cirrhosis 2.Delirium tremens 3.Esophageal varices 4.Wernicke-Korsakoff syndrome

4.Wernicke-Korsakoff syndrome

The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency? 1.The client has difficulty with balance when rising from the chair. 2.The client has lost the cognitive ability to fold his own clothes. 3.The client recognizes his children but has difficulty calling them by name. 4.When asked to pick up the cup, the client consistently fails to identify the cup.

4.When asked to pick up the cup, the client consistently fails to identify the cup.

A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study in order to monitor for adverse effects from this medication? 1.Platelet count 2.Blood glucose level 3.Liver function studies 4.White blood cell count

4.White blood cell count

A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1.Platelet count 2.Blood glucose level 3.Liver function studies 4.White blood cell count

4.White blood cell count

A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndrome-associated fact? 1.The client has experienced more than 1 sexual assault. 2.The client routinely incorporates foreign objects into the sex act. 3.The client actively and commonly initiates situations in which sex is forced. 4.The client regularly reexperiences the events associated with the assault.

4.The client regularly reexperiences the events associated with the assault.

The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis? 1."I'd be sure to have a panic attack if I left my house." 2."I couldn't touch a public doorknob unless I wore gloves." 3."Just the thought of getting into an elevator causes me to panic." 4."Speaking to more than 1 or 2 people would be impossible for me."

1."I'd be sure to have a panic attack if I left my house."

1.A birthday of March 30 2.A loss of interest in hobbies 3.A suicide attempt 6 months ago 6.Magnetic resonance imaging shows temporal lobe atrophy

The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? 1.Coffee, tea, and soda consumption should be limited. 2.If the client is compliant, the relapse of symptoms will never occur. 3.Psychotropic medications may cause mild cardiovascular symptoms. 4.Most schizophrenic clients are able to taper off their medications eventually.

1.Coffee, tea, and soda consumption should be limited.

A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time? 1.Remain with the client. 2.Put the client in a quiet room. 3.Teach the client deep breathing. 4.Encourage the client to talk about his or her feelings and concerns.

1.Remain with the client.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1.Setting limits on the client's behavior 2.Asking the client to leave the group session 3.Asking another nurse to escort the client out of the group session 4.Telling the client that they will not be able to attend any future group sessions

1.Setting limits on the client's behavior

A client's medication sheet contains a prescription for sertraline. 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.At the same time each evening

During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with post-traumatic stress disorder? 1.Explaining the unit rules 2.Making the client feel safe 3.Orienting the client to the unit 4.Stabilizing the client's psychiatric needs

2.Making the client feel safe

A client diagnosed with bipolar disorder is prescribed lithium carbonate. The nurse who administers the medication knows that lithium is used primarily to treat which condition? 1.Suicidal ideations 2.The manic phase of bipolar disease 3.Both depressive and manic episodes 4.The depressive phase of bipolar disease

2.The manic phase of bipolar disease

3."I keep reliving the abuse."

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention should the nurse include in the plan? 1.Suggesting a reduction of medication 2.Allowing increased "in-room" activities 3.Increasing the level of suicide precautions 4.Allowing the client off-unit privileges as needed

3.Increasing the level of suicide precautions

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1.Suggesting a reduction of medication 2.Allowing increased "in-room" activities 3.Increasing the level of suicide precautions 4.Allowing the client off-unit privileges as needed

3.Increasing the level of suicide precautions

A client diagnosed with schizophrenia has a new prescription for risperidone. Which baseline laboratory result should the nurse review before administering the first dose of this medication? 1.Platelet count 2.Blood clotting tests 3.Liver function studies 4.Complete blood count

3.Liver function studies

A client diagnosed with depression has a prescription for sertraline. The nurse should withhold the medication and question the prescription if the client has a history of which disorder? 1.Diabetes mellitus 2.Myocardial infarction 3.Phenelzine sulfate use 4.Irritable bowel syndrome

3.Phenelzine sulfate use

The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client? 1.Delay such planning until the client asks to participate in milieu. 2.Encourage the client to play solitaire while providing a deck of cards. 3.Provide a structured daily program of activities, and encourage the client to participate. 4.Offer the client a menu of daily activities and insist that the client participate in all of them.

3.Provide a structured daily program of activities, and encourage the client to participate.

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1.The informed consent does not need to be obtained. 2.The informed consent should be obtained from the family. 3.The informed consent needs to be obtained from the client. 4.The primary health care provider will provide the informed consent.

3.The informed consent needs to be obtained from the client.

The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the best therapeutic value? 1."Why do you think this is a wise decision?" 2."I don't understand. Only you can help you?" 3."You've decided not to take your medication. Is that right?" 4."Do you recall what it was like before you started your medication?"

4."Do you recall what it was like before you started your medication?"

The nurse suspects that the client hospitalized with a diagnosis of depression could benefit from further development of coping strategies. Which client statement supports this suspicion? 1."I know now that I can't be all things to all people all the time." 2."It is important for me to take my medications just as prescribed." 3."It's been good to learn better ways to deal with the stresses in my life." 4."I know that I won't become depressed again as long as I reduce my stressors."

4."I know that I won't become depressed again as long as I reduce my stressors."

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1.Encouraging quiet reading and writing for the first few days 2.Identification of physical activities that will provide exercise 3.No socializing activities until the client asks to participate in milieu 4.A structured program of activities in which the client can participate

4.A structured program of activities in which the client can participate

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1.Encouraging quiet reading and writing for the first few days 2.Identification of physical activities that will provide exercise 3.No socializing activities, until the client asks to participate in milieu 4.A structured program of activities in which the client can participate

4.A structured program of activities in which the client can participate

Which is the appropriate nursing intervention to address the poor nutritional intake demonstrated by a client diagnosed with depression? 1.Weigh the client 3 times per week before breakfast. 2.Explain to the client the importance of a good nutritional intake. 3.Report the nutritional concern to the psychiatrist, and obtain a nutritional consultation as soon as possible. 4.Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.

4.Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.

A client admitted 72 hours ago with a diagnosis of depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior? 1.Institute the unit's suicide precaution protocol. 2.Alert the client's psychiatrist of these changes immediately. 3.Notify the staff of these observations at today's team meeting. 4.Ask the client directly about the presence of any suicide-related thoughts.

4.Ask the client directly about the presence of any suicide-related thoughts.

A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's altered demeanor? 1.Continue to assess the client's behaviors and document clearly in the chart. 2.Report to the psychiatrist that the client is adapting to the unit and is feeling safe. 3.Notify the health team of these observations and alert them to the suspicion that the client is contemplating suicide. 4.Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide.

4.Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide.

What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget? 1.Escort the client to a private, low-stimulus room. 2.Engage the client in a nonthreatening conversation. 3.Allow the client to pace unless the behavior becomes aggressive. 4.Share the observation with the client so the behavior can be recognized

4.Share the observation with the client so the behavior can be recognized

A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy? 1.Daily medication therapy 2.Involvement with a support group 3.Intense stress management training 4.Short exposure to the phobic object

4.Short exposure to the phobic object

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1.Call the client's family to arrange for transportation. 2.Contact the client's primary health care provider (PHCP). 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment.

. 2.Contact the client's primary health care provider (PHCP).

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? 1.When told that a beloved pet has died, the client responds, "OK." 2.The client giggled while describing being physically abused as a child. 3.The client's facial expressions are unchanged during the entire admission process. 4.When staff members attempt to engage the client in conversation, the client only mumbles.

2.The client giggled while describing being physically abused as a child.

A client is being seen at his primary health care provider (PHCP) office. The client has a history of schizophrenia and has been taking a new psychotropic medication for 3 weeks. Which finding(s) indicate a need for follow-up? Select all that apply. 1.The client has reported sleeping less. 2.The client's cholesterol level is elevated. 3.The client reports a decrease in appetite. 4.The client gained 8 pounds since the last visit. 5.The client's blood pressure is increased from baseline.

2.The client's cholesterol level is elevated. 4.The client gained 8 pounds since the last visit. 5.The client's blood pressure is increased from baseline.

A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom? 1.Teach self-grooming skills. 2.Reward cleanliness with unit privileges. 3.Monitor the adequacy of the antipsychotic dosage. 4.Encourage frequent fluid intake and a high-fiber diet.

4.Encourage frequent fluid intake and a high-fiber diet.

The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1.Get adequate sunlight. 2.Continue driving as usual. 3.Avoid foods rich in potassium. 4.Get up slowly when changing positions.

4.Get up slowly when changing positions.

4.Lightheadedness and paresthesias

4.Nonstop physical activity and poor nutritional intake

The client tells the nurse that she cannot leave home without checking numerous times that "everything electrical has been shut off." The client's statement supports which mental health diagnosis? 1.A phobia 2.Generalized anxiety disorder 3.Post-traumatic stress disorder 4.Obsessive-compulsive disorder

4.Obsessive-compulsive disorder

4.Obtain postural blood pressure prior to each medication administration.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1.The client has acidotic blood. 2.The client is probably overreacting. 3.The client is fluid volume overloaded. 4.The client is probably hyperventilating.

4.The client is probably hyperventilating.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mm Hg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1.The client has acidotic blood. 2.The client is probably overreacting. 3.The client is fluid volume overloaded. 4.The client is probably hyperventilating.

4.The client is probably hyperventilating.

The nurse suspects that a client prescribed clomipramine hydrochloride has been noncompliant with taking the medication as prescribed. Which client behavior would support the nurse's suspicion?

C. Frequently checking for the car key Rationale:Clomipramine is an antidepressant that is commonly used in the treatment of obsessive-compulsive disorder.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1.Setting limits on the client's behavior 2.Asking the client to leave the group session 3.Asking another nurse to escort the client out of the group session 4.Telling the client that he or she will not be able to attend any future group sessions

1 Setting limits on the client's behavior

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1.The client's noncompliance with medication therapy 2.The community's opposition to outpatient mental health clinics 3.The associated increased risk that the client may become homeless 4.The family's negative reaction to transferring the client to community-based care

1 The client's noncompliance with medication therapy

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1.Begin to teach relaxation techniques. 2.Encourage the client to discuss the assault. 3.Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation.

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