MH Quiz 5

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of hte following statements shoudl the nurse make?

"Come with me. Here is a milkshake to drink." When working with a client who is experiencing mania, the nurse should provide short, firm, and concise directions, which can provide a feeling of safety for the client and can distract the client from inappropriate activities, such as vigorous exercise. An appropriate activity for the client is to accompany the nurse to a quiet place away from the clients who are trying to eat. Client nutrition is important, but the client often needs foods that can be held in the hand and eaten easily while walking. The client is unlikely to be able to sit in one place for long enough to complete a meal when experiencing mania.

A nurse is evaluating teaching for a client who has newly diagnosed depression and new prescription for bupropion. Which of the following statements by the client indicates understanding of the teaching?

"I may not notice a lifting of my mood for at least 2 weeks." Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI). As with other antidepressants, it can take 2 to 4 weeks for therapeutic effects to occur when taking bupropion.

A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the following statements by the client indicates understanding of the teaching?

"I should notify my provider if I develop a skin rash." Serious skin rashes, such as Stevens-Johnson syndrome, can occur while taking fluoxetine. The client should notify the provider if a rash occurs.

A nurse working in suicide prevention is discussing suicide interventions with a newly hired nurse. Which of the following statements indicates that the newly hired nurse understands when a tertiary intervention is needed?

"I should provide counseling for the family following the suicide of a client." Providing counseling for the family following the suicide of a client is an example of tertiary intervention. Following the suicide of a client, family and friends are, themselves, at risk for suicide, and can be helped by therapeutic communication. They may require referral for grief counseling or other supportive measures.

A nurse is providing teaching for a client who has a new prescription for clozapine. Which of the following statements indicates the client understands the teaching?

"I will rise slowly from a lying position to prevent fainting while taking this medication." Clozapine can cause orthostatic hypotension, especially during the first few weeks of therapy. The client should be taught to rise slowly from a lying or sitting position.

A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation?

"It was good. The Queen of England visited me there." Confabulation occurs when a client who has dementia unconsciously makes up or fills in made-up information when she has memory loss. Confabulation is sometimes mistaken for lying. However, lying is done consciously and confabulation is done unconsciously to maintain self-esteem.

A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention

"There is no gate for me to open." This reply can be viewed as argumentative by the client and is nontherapeutic for communicating with a client who is experiencing a delusion.

A nurse is talking with a client who has schizo. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following response by the nurse is appropriate?

"What are the voices telling you to do?" This statement recognizes the risk involved with a command hallucination and asks the client directly about the hallucination. This is a therapeutic approach to communicating with a client who is experiencing a hallucination.

A nurse is providing medication teaching for a client who has a new prescription for phenelzine. Which of the following statements should the nurse include in the teaching?

"You should change positions slowly while taking this medication." Clients should change positions slowly while taking an MAOI due to the risk of orthostatic hypotension. Lightheadedness and fainting are common when taking phenelzine.

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

A client who has a WBC of 2,900 cells/mm3 A white blood cell count of 2,900 cells/mm3 is below the normal reference range of 5000 to 10000 cells/mm3 . The client who takes clozapine is at risk for agranulocytosis; therefore, a client who has a WBC of less than 3000 mm3 should have clozapine withheld and treatment stopped until the WBC returns to normal. Clozapine should be permanently stopped if a client's WBC falls below 2000 mm3.

A nurse in the emergency dept. is planning care for a client who is admitted for an overdose of PCP. Which of the following actions should the nurse plan to take?

Administer ammonium chloride. Ammonium chloride acidifies the urine and promotes excretion of PCP. In addition, the nurse should monitor the client's respiratory status and be prepared to assist with intubation and mechanical ventilation.

A nurse is preparing to administer selegiline for a client who is admitted with major depression. Which of the following actions should the nurse take?

Apply to dry skin on the client's upper thigh. Selegiline, a monoamine oxidase inhibitor (MAOI) is administered only by the transdermal route to treat depression. It can be administered orally to treat Parkinson's disease and other disorders.

A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?

Carbamazepine Carbamazepine, an antiseizure medication and a mood stabilizer, is prescribed to treat and prevent mania in clients who have bipolar disorder.

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

Increase caloric intake to prevent weight loss. Weight gain, dyslipidemia, and increases in blood glucose are common adverse effects of risperidone.

A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

Give the client extra time to communicate needs. Clients who have vegetative signs of depression have slowed thought processes and might take extra time to reply to questions or to verbalize thoughts. The nurse should display patience and give the client extra time to communicate.

A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling. "You are all making fun of me." Which of the following behaviors is this client displaying?

Ideas of reference Ideas of reference occur when a client believes that conversations of others always concern him and that others are ridiculing him.

A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care?

Institute consequences for manipulative behavior. The nurse should work with the client to develop a behavior plan that includes specific consequences for manipulative behavior.

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care?

Limit the client's choices for daily activities. Limiting the client's choices is appropriate for a client who has dementia as this intervention decreases the client's level of anxiety.

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Limit the number of questions asked during assessments Minimizing the number of questions is appropriate since a client who has acute schizophrenia has difficulty concentrating on information and answering assessment questions. The nurse should plan to use other sources of client information, such as medical records, family members, or reports from other interprofessional sources.

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

Maintain a nonjudgmental attitude. When developing a therapeutic relationship with any client, including a client who has an addictive disorder, it is important that the nurse remain nonjudgmental, showing positive regard for the client as a person.

A nurse is planning care for a client who is being treated for acute PCP intoxication. Which of the following should the nurse include in the plan of care?

Monitor for hypertension. PCP intoxication can cause hypertension and tachycardia, as well as seizures and coma. The nurse should monitor the client for elevated blood pressure and pulse and administer a vasodilator, such as nitroprusside, as indicated.

A nurse in an acute care mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?

Monitor the client's whereabouts at all times. Clients who have depression and exhibit a sudden change in behavior are at risk for suicide and suicide precautions should be included in the plan of care. Antidepressant medications generally take 1 to 3 weeks before improvement is seen. A cheerful mood with no signs of a depressive state 3 days after treatment begins might indicate that the client has made a decision to commit suicide.

A nurse is assessing for the presence of extrapyramidal side effects in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS?

Muscle spasms of the neck Fidgeting behavior Tremors of the hands

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

Neuroleptic malignant syndrome The client's findings indicate possible neuroleptic malignant syndrome which is a potentially life-threatening adverse effect of antipsychotic medications. The nurse should promptly recognize and report findings of neuroleptic malignant syndrome since prompt treatment is necessary.

A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should the nurse identify as primary risk factors for this disorder?

Past history of childhood trauma. A history of trauma in childhood is a primary risk factor for depression.

A nurse is collection a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. Which of the following is an expected finding?

Personal history of alcohol use disorder. Wernicke-Korsakoff syndrome is a type of secondary dementia as a result of thiamine deficiency that is commonly associated with alcohol use disorder. The syndrome results in confusion and memory loss and is treated with thiamine replacement therapy.

A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

Remain with the client. The greatest risk to this client is self-injury from impulsive behavior; therefore, the nurse should stay with the client to reduce anxiety and help the client feel safe.

A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?

Set limits on the client's behavior and be consistent in approach. When caring for a client who is experiencing a manic episode, the nurse should communicate acceptable behavior to the client and should be consistent with consequences when the behavior plan is not followed.

A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the following is an expected finding?

Suspended from school several times in the past year Conduct disorder is an impulse-control disorder which includes a long-term pattern of violating the rights of others and performing violent or hostile acts.

A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention?

Take the client outside for a walk. Clients who are experiencing mania are at risk for physical exhaustion; therefore, the nurse should redirect the client to a different activity that will decrease stimulation and slow the client's physical activity expenditure.

A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia

Twisting tongue movements Twisting tongue movement, tics, sudden involuntary jerking movements of the extremities, and other findings occur in TD. The nurse should notify the provider of these findings since treatment includes reducing dosage of antipsychotic medications or perhaps changing to a second-general antipsychotic medication.

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?

he client's behavior has become impulsive in the past few weeks. The presence of impulsive behavior is a primary risk factor for suicide and clients who have mania can act in a manner which is hostile, aggressive, and impulsive.