Mental Health

A nurse on a mental health unit is using the SAD PERSONS scale to assess the risk of suicide among several clients. Which of the following clients should the nurse identify as having the highest risk?

A 15-year-old male client

A nurse is evaluating a client for schizophrenia and asks the client about their work, social and home life. For which of the following reasons should the nurse ask about these topics?

To gather insight into the client's background in order to guide care

A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as a cognitive symptom?

Unable to concentrate

A nurse on an inpatient mental health unit is teaching a newly licensed nurse about suicide prevention. Which of the following statements made by the newly licensed nurse indicates an understanding of the information presented?

"All sharp objects should be removed from the clients room."

A nurse is caring for a client in a behavioral health clinic. Exhibit 1 Exhibit 2 History and Physical​​ 1300:Middle-aged adult seen in a behavioral health clinic for continued reports of severe and recurrent hypersomnolence, mood reactivity, and distress.Client diagnosed with major depressive disorder after death of spouse 3 years ago. Client reports having lack of interest and pleasure, change in appetite and sleep. While client voiced no plan for self-harm, client admits that if they died, "That would be okay—a relief, actually."Client has been treated by multiple providers, tried several medications including fluoxetine, venlafaxine, and amitriptyline, and was compliant with dose increases and medication combinations, only to have the symptoms diminish and then return with the loss of their job.Electroconvulsive therapy (ECT) made a small difference in manifestations The client suffered memory loss surrounding the times of treatment, which ultimately was more distressful for the client than the mood disorder itself. Client eventually tapered off all medications, taking part in cognitive therapy, which was effective in minimizing the manifestations, but not bringing back the client's earlier interest and pleasure. Diagnosis: Major depressive disorder, recurrent The nurse is providing education to the client regarding phenelzine. Which of the following 3 statements indicate that the client needs further instruction?

"I can expect my blood Pressure to go up with this medication" "It is okay if I drink imported beer, but I must avoid wine" "I love overripe bananas, I am glad that I don't have to give them up"

A nurse is caring for a client who is scheduled for transcranial magnetic stimulation. When preparing the client for the procedure, which of the following statements should the nurse make?

"This procedure is effective when combined with psychotherapy."

A nurse is discussing findings of depression with a group of clients. Which of the following client statements indicates an understanding of the information?

"Thyroid problems can cause depression"

A nurse on an inpatient mental health unit is evaluating a client who was admitted for suicidal ideation for readiness for discharge. Which of the following statements by the client indicates they may be ready for discharge?

"When I get home, I will reach out to my friends if I start to feel down."

A nurse is providing teaching to a client who is to undergo electroconvulsive therapy (ECT) for depression. Which of the following information should the nurse provide?

"Your provider will likely schedule you for several treatments over a period of weeks."

A public health nurse is preparing a suicide prevention program for patrons of the local library. The nurse should inform the attendees that suicide is the second leading cause of death in which of the following age groups?

10-34

a nurse is providing a community health education class about suicide prevention. which of the following should the nurse identify as risk factors for suicide?(Select all that apply).

= substance use disorder = age greater than 45 years old =schizophrenia

A nurse is caring for a client who has schizophrenia. Which of the following should the nurse identify as a social determinant of health for the client?

Access to healthy foods

A nurse is creating a presentation about depression for a community health fair. The nurse should plan to report that depression is more prevalent among which of the following demographics?

Adult females

A nurse is caring for an adult client. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 Nurses' Notes 0730: Client was brought into the emergency department by emergency medical services (EMS) from their extended care facility for reports of altered mental status and decreased oral intake for past 2 days because of nausea.Client claims to be unaware of the reason for ED visit and reports blurry vision and feeling tired.Client is somnolent yet easily arousable. Client's speech is slow but answers simple questions. Observed dry oral mucous membranes, poor skin turgor, pronounced intention tremor.0750:Assisted client to bathroom. Client's gait unstable. Required verbal cues with task.0800:Review of medical recordClient was seen by primary care provider 1 week ago for low back pain after helping friends move a piano out of the house. No acute injury was found. Client was educated on the use of heat and massage therapy for the low back pain and was instructed to take ibuprofen three times a day. The nurse is reviewing the medical record. Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Client was brought into the emergency department by emergency medical services (EMS) from their extended care facility for reports of altered mental status and decreased oral intake for past 2 days because of nausea. Client claims to be unaware of the reason for ED visit and reports blurry vision and feeling tired. Client is somnolent yet easily arousable. Client's speech is slow but answers simple questions. Observed dry oral mucous membranes, poor skin turgor, pronounced intention tremor. Client was seen by primary care provider 1 week ago for low back pain after helping friends move a piano out of the house. No acute injury was found. Client was educated on the use of heat and massage therapy for the low back pain and was instructed to take ibuprofen three times a day. Lithium carbonate 300 mg by mouth three times a day Ibuprofen 600 mg by mouth three times a day Sodium 145 mEq/L, Potassium 3.5 mEq/L BUN 48 mg/dL, Creatinine 2.4 mg/dL Serum glucose 118 mg/dL Lithium level 2.5 mEq/dL 12-lead ECG revealed sinus bradycardia rate 52

Altered Mental status, Blurry Vision, Dry oral Mucous membranes, poor skin turgor, pronounced intention tremor, Ibuprofen 600 mg by mouth three times a day, BUN 48 mg/dL,Creatinine 2.4 mg/dL, Lithium level 2.5 mEq/dL, 12-lead ECG revea;ed sinus bradycardia rate 52

A school nurse is preparing a presentation for high school students on the relationship between substances and depression. Which of the following substances should the nurse plan to include as a contributing factor in the development of substance-induced depressive disorder?

Amphetamines

A nurse is caring for a client who has schizophrenia and is unaware of their own mental health. Which of the following is the client experiencing?

Anosognosia

A nurse is caring for a young adult client who experience as traumatic event and appears to be hallucinating. The client has no history of or evidence of risk factors for schizophrenia spectrum disorders and the client's toxicology screen is negative. Which of the following diagnoses provides the best explanation of the client's clinical manifestations?

Brief psychotic disorder

A nurse is instructing a client who is experiencing hallucinations about medication use. Which of the following statements should the nurse make?

Both prescription and OTC meds can sometimes cause hallucinations in some people

A nurse is reviewing assessment findings for a 22-year old client who was found wandering in the street. Which of the following manifestations suggests the client is experiencing positive symptoms of psychosis.

Clanging speech It is when you see or hear things that others are not experiencing

A nurse is reviewing the medical record of a client who has major depressive disorder. Which of the following assessment findings should the nurse expect for a client who has major depressive disorder?

Client reports having thoughts of death

A nurse is caring for a client who is being evaluated for schizophrenia spectrum disorder. Which of the following is used to determine a diagnosis of schizophrenia?

Clinical observation

A nurse is caring for a client who was admitted with suicidal ideation. The client tells the nurse they have several guns in their home. Which of the following types of interventions is the priority for the nurse to initiate?

Create a protective environment

A nurse is caring for a client who has been diagnosed with schizophrenia. Which of the following findings indicates that the client is in the residual phase of the disorder?

Decline in symptoms of pyschosis

A nurse is caring for a client who is experiencing psychosis and states that they are the POTUS. The nurse should identify that the client is experiencing which of the following?

Delusions

A nurse is caring for a child who is exhibiting tantrums, dysfunction in school, trouble with peers, and suicidal ideation. Which of the following should the nurse identify as being consistent with the client's findings?

Disruptive mood dysregulation disorder

A nurse in an outpatient clinic is caring for a client who has major depressive disorder and has reported suicidal thoughts. Which of the following is the first information the nurse should try to obtain from the client?

Does the client have a suicide plan

A nurse in a mental health clinic is taking a medical history on a client. The nurse should identify that which of the following factors in the client's history increases their risk for mental illness?

Early exposure to violence

A nurse is caring for a client who has been diagnosed with schizophrenia. Which of the following should the nurse identify as a positive symptom?

Hallucination

A nurse working in a community health center is providing an in-service to a group of residents about schizophrenia. Which of the following should the nurse include as an environmental risk factor for this condition?

Experiencing poverty

A school nurse is creating a presentation about mental health for a group of middle school students. Which of the following topics should the nurse prioritize when preparing this presentation?

Factors that contribute to suicide

A nurse is speaking with a client about the potential impact of living with a serious mental illness. Which of the following pieces of information should the nurse share?

Having a job is positively associated with recovery from a serious mental illness.

A nurse is providing education to a group of staff members about risk factors for schizophrenia. Which of the following risk factors should the nurse include?

Having a twin sibling who has the disorder

A nurse is caring for a client who has been diagnosed with schizophrenia. The client is exhibiting delusional behavior stating that a new nurse is from the FBI and is stealing their thoughts and ideas. Which of the following statements should the nurse make?

I can see you are concerned. The new nurse is not from the FBI and will not harm you.

A nurse at a community treatment center asks a client about their use of a prescribed anti-psychotic medication that should be taken daily. Which of the following client statements should suggest to the nurse that the client is not adhering to their medication treatment plan?

I sometimes go a few days without taking my medication

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states "I'm feeling really down and don't want to talk to anyone right now." which of the following responses should the nurse make?

I'll just sit here with you for a few minutes then

A nurse is caring for a client who has an SMI and has recently been released from prison. Which of the following factors related to being released from prison increases the client's risk for relapsing?

Inability to find housing

A nurse is caring for a client in a Veterans' Administration facility. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Medical History Day 1 1630: Client seeks treatment for areas of frostbite to the fingers, toes, and nose. Client is known to this facility and has a history of schizophrenia. States they have been without medication for "a long time." Client was last seen in facility three months ago when aripiprazole was prescribed. At that time, client was discharged to a community shelter. Client reports leaving the shelter and currently resides in a tent in the park. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

Living situation due to =physiological needs

A nurse is caring for a client who is hyperactive, pacing down the hallway, and exhibiting poor concentration during group therapy. Which of the following is characteristic of the client's manifestations?

Mania

A client who has schizophrenia shares with their nurse that they are feeling lonely and isolated. Which of the following actions is the nurse's priority?

Share information about support groups for people who have SMIs

A nurse is caring for a client in an outpatient clinic. Exhibit 1 Exhibit 2 Nurses' Notes​ 0800:Adult client whose spouse died recently reports headache and fatigue. "I worry that I am just getting worse." Reports being "always tired" yet waking "well before the alarm." Headache is dull but persistent despite intervention. Client reports no appetite and no interest in doing anything. Client has had troubles at work because they "cannot seem to concentrate."Client alert and oriented. Thought process clear. Client tearful during interview, stating, "I'm sad all the time." 0900:Client reports being active with family and friends until 3 months ago. "I feel like I have nobody." "I thought the death of my spouse was hard. It seems the months after have been worse. I am not sure I can do this anymore. My family doctor prescribed me some medicine for my depression but I stopped taking it after a week because it did nothing for me." Complete the following sentence by using the list of options. The nurse should first address the client's Select... as evidenced by the client's Select... .

Safety, Noncompiance

A nurse is talking with a client about mental health care and services. The client asks "What is the difference between psychosis and schizophrenia. Which of the following responses should the nurse make?

Psychosis describes conditions where a person loses contact with what is real. Schizophrenia is a mental health illness where the person can show manifestations of psychosis

A nurse is caring for a client who has schizophrenia. Exhibit 1 Exhibit 2 Nurses' Notes Day 1 1030: A 28-year-old client who has schizophrenia was admitted. Diagnosed 10 years ago. Brought in by partner who states client is restless, refusing to eat or drink, movements are slow, and not speaking for the last several days. Day 1 1330: Client ate 25% of meal with assistance. Able to walk to bathroom with assistance. Does not respond to nurse's voice. Day 1 1930: Nurse enters client's room. Client is in bed and unable to move. Eyes are open. In stupor-like state. Obtained vital signs and notified client's provider. The nurse is reviewing the client's medical record. Select the "3" findings that require immediate follow-up by the nurse.

Temperature Stupor-like state Muscle ridgit

A nurse is assessing a client who has a diagnosis of mania related to bipolar disorder. Which of the following behaviors should the nurse expect the client to exhibit?

The client is demonstrating risky behavior

A nurse is caring for a client who is at risk for developing schizophrenia. Which of the following findings should the nurse identify as an environmental risk factor?

Using cannabis

A nurse is providing discharge instructions for a client who is prescribed clozapine. Which of the following information should the nurse include?

Weekly blood draws will need to be done while taking this medication.

A nurse is caring for a client who has schizophrenia. Which of the following questions should the nurse ask during the exploitation phase of the nurse-client relationship?

Which stress reduction techniques are you finding helpful alongside your medication?

A nurse is talking with the family of a 28 year old client who has been diagnosed with schizophrenia. The client's parent asks, "Will my child ever be able to have a good quality of life?" Which of the following responses should the nurse make?

With treatment and support your child will be able to live a productive and rewarding life

A nurse is caring for a client who has schizophrenia. Which of the follwoing describes the physiological changes caused by exposure to risk factors for this disorder?

decreased gray matter volume in the brain

A nurse is caring for a client who has persistent depressive disorder. When educating the client about their illness, which of the following statements should the nurse make?

persistent depressive disorder is a mild chronic form of depression

A school nurse is preparing a presentation about suicide prevention for high school. Which of the following should the nurse include as modifiable risk factors for suicide?

Access to firearms

A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client is experiencing psychosis?

Hallucinations

A nurse is providing teaching to a client who is to undergo transcranial magnetic stimulation (TMS) for depression. Which of the following information should the nurse provide?

You may experience a mild headache following the proedure