Mental Health Practice
A nurse is teaching the parent of a 10-year-old child who has ADHD and a new prescription for dextroamphetamine. Which of the following instructions should the nurse include in the teaching "You should expect your child to gain weight while taking this medication." "Administer the first dose of medication to your child 30 minutes before breakfast." "You should expect your child to have diarrhea while taking this medication." "Administer the last dose of medication to your child 6 hours before bedtime."
"Administer the last dose of medication to your child 6 hours before bedtime R: A/E of dextro. is insomnia
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism "I put in extra hours at work so I won't think about drinking." "I know that wine is good for my heart, so that's why I drink some each evening." "I make up for my drinking by taking my partner on nice vacations." "I am able to go to work every day, so I don't have a problem."
"I am able to go to work every day, so I don't have a problem
A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness "I am going to order a wheelchair for when I'm unable to walk." "I am going to stop paying my bills since I won't be around much longer." "I wish you would go take care of somebody who actually needs you." "I am sure I'm going to be able to continue to care for myself without help."
"I am going to order a wheelchair for when I'm unable to walk." R: pt is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, indicative of acceptance.
A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief "I wish I had been nicer and more generous with my wife before she died." "I told my wife to go to the doctor, but she wouldn't listen to me." "I think about my wife all the time when I go on outings with my family." "I feel so empty without my wife that it's hard to get up every morning."
"I feel so empty without my wife that it's hard to get up every morning." R: difficulty carrying on w normal activities indicates a risk for complicated grief
A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching "I will avoid social events until my partner has completed treatment." "It is important for me to focus my attention on my partner's addiction." "I will not take charge of my partner's work responsibilities." "I want my partner to promise to change addictive behaviors."
"I will not take charge of my partner's work responsibilities It is important for the individual who has the substance use disorder to take charge of personal responsibilities.
A nurse is teaching coping strategies to a client who is experiencing depression related to intimate partner abuse. Which of the following statements by the client indicates an understanding of the teaching I will spend extra time at work to keep from feeling depressed." "I will talk about my feelings with a close friend." "I will be able to learn how to prevent my partner's attacks." "I will use meditation instead of taking my antidepressant."
"I will talk about my feelings with a close friend." R: discussion feelings w a support person is effective coping
A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior "If you do my homework for me, I won't bother you for the rest of the day." "Mom is always upset." "It's not the children's fault. It's mine." "It's your fault that we're having problems as a family."
"If you do my homework for me, I won't bother you for the rest of the day R: this is an ex of manipulative behavior
A nurse is teaching the parents of a client about their daughter's diagnosis of bulimia nervosa. Which of the following statements made by the parents indicates an understanding of their daughter's illness "This disease will increase our daughter's risk for high blood pressure." "It is important for our daughter to have regular dental checkups." "We need to weigh our daughter daily for several weeks, then once per week." "Bleeding during our daughter's periods will increase because of this disease."
"It is important for our daughter to have regular dental checkups For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, frequent dental checkups are essential.
A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make
"It is not uncommon to feel angry toward yourself or others."
A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make "Why do you think you deserve this punishment?" "Don't worry about being punished by God." "Let's talk about what is upsetting you." "You shouldn't say things that will upset you so much."
"Let's talk about what is upsetting you." R: nurse is acknowledging the ot concerns and is showing desire to understand what the pt is thinking and feeling
A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the nurse "Succinylcholine will enhance the therapeutic effects of this treatment." "Succinylcholine is given to reduce muscle movements during therapy." "Succinylcholine will decrease the anxiety level that you might experience with this treatment." "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure."
"Succinylcholine is given to reduce muscle movements during therapy R: succinylocholine is a muscle paralyzing agent that will decrease muscle movement during the procedure so that injury is less likely to occur
A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching
"Take this medication with food R: Li can cause GI distress
A nurse in the emergency department is admitting a client who reports a headache along with heart palpitations after having a glass of wine with dinner a few hours ago. The client has a history of depression and has a blood pressure of 210/105 mm Hg. Which of the following questions should the nurse ask first "Do you have a family history of hypertension?" "When did you last see your primary provider?" "What medications are you currently taking?" "Do you currently use relaxation techniques for increased stress?"
"What medications are you currently taking?" R: If the pt is taking MAOI to tx depression, they are at a greater risk for hypertensive crisis, it can also be precipitated by tyramine containing food
A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching You may notice an increase in saliva while taking this medication." "You may experience difficulties with sexual functioning while taking this medication." "You should expect an improvement in symptoms of depression in 3 to 4 days." "You may notice a temporary ringing in the ears when starting this medication."
"You may experience difficulties with sexual functioning while taking this medication R: SSRI can cause sexual dysfunction
A nurse who is working on a mental health unit should recognize that which of the following are indications for the use of electroconvulsive therapy (ECT)? (Select all that apply A client who is suicidal and in need of rapid treatment A client who has recently been diagnosed with severe depression A client who has bipolar disorder with rapid cycling A client who has mania and has not responded to medication therapy A client whose depression is secondary to situational difficulties
- Pt who is suicidal and need rapid tx R: ECT is a rapid, definitive response for suicidal pt -pt w bipolar d/o w rapid cycling R: works best for these pt -pt w mania and not responding to med therapy
A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero
1.5
A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent
A 35-year-old client who has major depressive disorder R: pt w majar depressive d/o can make decisions unless legally incompetent
A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs
A client who has severe Alzheimer's disease R: these pt are typically confused, have memory difficulties, tend to wander, and will need assistance
A nurse in an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first A client who does not recognize familiar people A client who cannot verbalize his needs A client who is awake and disoriented at night A client who is experiencing delusions of persecution
A client who is experiencing delusions of persecution R: greatest risk due to the pt belief that a person in power is out to harm him.
A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse
A family where one or both parents witnessed intimate partner violence in the home as children R: They are more likely to become abused themselves.
A nurse is reviewing the medication administration record for a client who is experiencing the adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects Blurred vision Orthostatic hypotension Dry mouth Acute dystonia
Acute dystonia
A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate Feelings of remorse Extended periods of depression Deficits in intellectual functioning Aggression toward animals
Aggression toward animal
A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse A school-age girl who has bruises on her knees An older adult client who is bedbound and has a stage IV pressure ulcer An adolescent who has a vaginal candida infection A young adult who is pregnant and has a sprained ankle
An older adult client who is bedbound and has a stage IV pressure ulcer A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.
A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take?
Ask the client what the voices are saying R: to determine if the pt or others are at risk for injury
A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take Call the family member to the side to inquire if she has questions or concerns about the treatment plan. Advise the family member that this treatment plan has been developed specifically for the client to follow. Ask the family member if she has any thoughts or questions about the treatment plan. Document that the family member does not support the medication treatment plan.
Ask the family member if she has any thoughts or questions about the treatment plan
A nurse in a mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following postdischarge activities should the nurse plan to include Taking the oral medication buprenorphine to prevent alcohol use Attending a relapse prevention group several times each week Beginning a methadone treatment program at a local center Living with her mother who has promised to keep her away from alcohol
Attending a relapse prevention group several times each week R: most effective relapse prevention is a 12 step program such as AA
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening Offering self Use of silence Attention to body language Reflection of feelings
Attention to body language R: active listening involves identifying verbal and nonverbal communication
A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following
Clang association R: clang often rhymes or contains a string of words tha can have the same beginning sounds
A nurse in a provider's office is collecting a health history from the parent of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the parent is the priority for the nurse to report to the provider Reduced appetite Fatigue Dark urine Sweating
Dark urine R: greatest risk for a child is liver damage from atomoxetine, which can progress to failure and death.
A nurse is caring for a client who is receiving hospice care for an inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement Discuss spiritual issues in a conversational manner. Engage in a formal discussion of the client's religious beliefs. Prompt the client to be specific when asking questions related to his own spirituality. Offer suggestions based on personal spiritual values.
Discuss spiritual issues in a conversational manner
A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first Recommend the client shave her hair. Suggest wearing a scarf to cover her hair loss. Discuss the importance of hair with the client. Provide information on resources for obtaining a wig.
Discuss the importance of hair with the client R: 1st action for a nurse is to assess the pt, the experience of anticipatory grieving begins w the importance of the expected loss
A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take Do not administer the lorazepam. Request a prescription for IV lorazepam. Request that another nurse attempt to administer the lorazepam. Place the lorazepam in the client's food.
Do not administer the lorazepam R: pt who is involuntarily admitted have the right to refuse tx
A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include Additional acute episodes of depression are unlikely following inpatient care. Early identification of changes, such as decreased social involvement, is important. Medication compliance will prevent further need for inpatient hospitalization. It is helpful to regularly reinforce to the client that things will get better.
Early identification of changes, such as decreased social involvement, is important R: decreased social involvement in a manifestation of depression, and early identification of findings can lead to early intervention
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take Gather supplies for endotracheal intubation. Administer a beta blocker intravenously. Position the client in a low-Fowler's position. Place a cooling blanket over the client.
Gather supplies for endotracheal intubation R: the expected finding is resp depression
A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team Calling family members Spending time alone Giving away possessions Excessive crying
Giving away possession R: giving away possessions indicates that the pt is a greater risk for suicide.
A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect Polyphagia Hypertension Decreased temperature Depressed mood
Hypertension Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body temperature, energy levels, and metabolism.
A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan Develop a code word that means "time to go." Identify signs of escalation of violence. Have a predetermined place to go in the event of violence. Keep a hidden packed bag of necessities.
Identify signs of escalation of violence
A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal body weight. Which of the following interventions should the nurse include in the plan Include a liquid supplement with meals. Identify the client's trigger foods. Allow the client at least 1 hr for each meal. Weigh the client at bedtime each day.
Identify the client's trigger foods R: to help pt understand the thoughts and behaviors that relate to the food
A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider Obsessive attention to detail Inability to sleep Reports of fatigue Isolation from others
Inability to sleep R: pt is extremely active and doesn't sleep, which can lead to relapse.
A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect Increased creatine phosphokinase (CPK) Increased low-density lipoproteins (LDL) Decreased fasting blood glucose (FBG) Decreased aspartate aminotransferase (AST)
Increased creatine phosphokinase (CPK) R: it is an enzyme released when muscle tissue is damaged
A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first
Inform the client that her admission is confidential
A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD) Clinging behaviors directed toward a teacher Increased time spent sleeping Intense focus on school work Lack of interest in an upcoming holiday
Lack of interest in an upcoming holiday R: pt w PTSD will have - moods, child can also have loss or lack of interest and participation in significant activities.
A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching
Language delay R: typical manifestation
A nurse is planning care for a client who constantly threatens others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation Nonmaleficence Veracity Justice Autonomy
Nonmaleficence R: it is the responsibility of the nurse to not harm the pt.
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment Diarrhea Heavy menstrual bleeding Tachycardia Orthostatic hypotension
Orthostatic hypotension R: low wt, electrolyte imbalance, starvation, and dehydration can cause this
A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care Offer the client various choices for meal selection. Assign different nursing personnel for each shift. Permit the client to perform daily rituals to decrease anxiety. Maintain an environment that has low lighting.
Permit the client to perform daily rituals to decrease anxiety R: allowing them to do so will decrease frustration and anxiety
A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following is the priority action by the nurse Schedule the client for group therapy sessions. Maintain consistent rules. Provide frequent high-calorie snacks. Avoid the use of value judgments.
Provide frequent high-calorie snacks R: Maslow's requirement is for adequate nutrition
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect Sedation Rhinorrhea Bradycardia Hypothermia
Rhinorrhea R: rhinorrhea and flu like manifestions such as yawning, sneezing, and abd pain
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client Behave in a friendly manner toward the client. Set realistic limits on the client's behavior. Show respect for the client's need for isolation. Act as a role model for assertiveness.
Set realistic limits on the client's behavior R: these pt can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive.
A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data Erythrocyte sedimentation rate 18 mm/hr Hemoglobin 15 g/dL Serum T4 5 mcg/dL Sodium level 125 mEq/L
Sodium level 125 mEq/l R: In the presence of low Na+ levels, renal excretion of Li is reduced and the pt is at risk for Li toxicity
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression Male gender Hyperthyroidism Substance use disorder Being married
Substance use disorder Clients who have a substance use disorder are at an increased risk for the development of depressive disorders.
A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for her deceased partner. Which of the following actions should the nurse take Move the client to a room near the nurses' station. Limit visitors until the client is oriented to her environment. Tell the client that her partner is deceased. Talk with the client about activities she enjoyed with her partner.
Talk with the client about activities she enjoyed with her partner R: talking about + experiences can help distract her from disorientation
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following nursing interventions assists in orienting the client to reality Discourage the client from reminiscing about her past. Overlook the client's frustration with communication. Talk with the client about scheduled daily activities. Present multiple options when offering the client choices.
Talk with the client about scheduled daily activities R: this can orient the pt to time and reality throughout the day
During a client's initial interview in a mental health inpatient setting, the nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors The client is interested in what the nurse is saying. The client is attempting to manipulate the nurse. The client is physically attracted to the nurse. The client needs to feel accepted by the nurse.
The client is interested in what the nurse is saying The client's posture and eye contact demonstrate that she is interested in the interview and what the nurse is saying.
A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect The client recently lost a grandparent in a motor vehicle crash. The client's town was hit by a tornado. The client's youngest son is leaving for college. The client is ambivalent about her upcoming retirement.
The client recently lost a grandparent in a motor vehicle crash The client experiences a situational crisis when an unexpected event occurs.
A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication The client reports a sore throat. The client reports being constipated for 2 days. The client reports feeling dizzy when getting out of bed. The client has gained 1.4 kg (3 lb) in the past month.
The client reports a sore throat R: clozapine can lead to a fatal blood d/o, agranulocytosis. this is a severe drop in WBC which leaves them at risk for infection. Nurse should w/hold
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client The client will take prescribed medications as scheduled. The client will express feelings of frustration. The client will refrain from self-mutilation. The client will participate in group therapy.
The client will refrain from self-mutilation R: greatest risk is injury to self or others
A charge nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following information should the nurse include in the teaching Client confidentiality applies until the client dies. Privileged communication protects nurse-to-nurse communication. The duty to protect third parties requires a nurse to testify about a client. The right to treatment ensures individualized care.
The right to treatment ensures individualized care The Hospitalization of the Mentally Ill Act of 1964 requires that clients admitted to an inpatient mental health facility have a right to individualized treatment.
A charge nurse is developing an educational program about schizophrenia. Which of the following manifestations should the nurse include as a negative symptom of schizophrenia Concrete thinking Thought blocking Echolalia Posturing
Thought blocking R: thought block is a - symptom of schizo. It is a sudden interruption in pt thought processes usually due to internal stimuli
A nurse is caring for a client who was admitted following an overdose of amitriptyline. The nurse should monitor the client for which of the following adverse effects associated with this medication Loose stools Urinary retention Fever Dyspnea
Urinary retention Urinary retention is an anticholinergic effect of amitriptyline. Therefore, the nurse should monitor for this as an adverse effect.
