Psychosocial Test #3

A nurse is collecting data from a client hose home was destroyed by a fire. Which of the following responses should the nurse make first?

"Are you experiencing feelings of hopelessness?"

A nurse is assisting in the mooning hygiene care of a client who cognitively impaired. Which of the following statements should the nurse make?

"Let me help you get your toothbrush."

A nurse is reinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make?

"have you considered participating in a sport to help you control your aggression?"

A nurse is assisting in the development of a staff educational inservice about depression. Which of the following factors should the nurse identify as a primary risk factor for depression?

Chronic illness

A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which of the following should she include an herbal supplement the client might use to treat the symptoms of depression?

St. John's Wort

A nurse is caring for client who has dementia. Which of the following actions should the nurse take?

stand in front of the client when speaking

A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse include?

"Expect that your mood might take one to three weeks to begin improving"

A nurse is monitoring communication between a client who has alcohol use disorder and her partner. Which of the following communication patterns of the client's partner should the nurse identify as being effective?

"I become very angry when you get drunk."

A nurse is reinforcing teaching for a client who is depressed and has a prescription for fluoxetine 20 mg PO twice daily. The nurse should identify that which of the following state emts by the client demonstrates an understanding of the teaching?

"I need to report weight loss or gain to my provider while taking this medication"

A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?

"I should call the provider if I experience excessive sweating and muscle twitching"

a nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate?

"I will help yo sit up and get your slippers on."

A nurse is caring for a client who states, "this has been the worst day of my life." Which of the following responses should the nurse make?

"Tell me about your day."

A nurse on a mental health unit is reinforcing teaching about informed consent with a newly licensed nurse. which of the following statements indicates an understanding of the teaching?

"The consent form should have the name of the provider who is performing the procedure on the form."

A nurse is caring for a client who states that she does not want to go to physical therapy after having a below-the-knee amputation. Which of the following response should the nurse make?

"What are your feelings about going to physical therapy?"

A nurse is collecting data from a client who uses alcohol "to cope with stress." Which of the following questions should the nurse ask?

"What daily activities are disrupted because of your alcohol consumption?"

A nurse is caring for a client who recently lost his child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask?

"have you had any thoughts of harming yourself?"

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT). Which of the following client statements indicates to the nurse a need for further teaching?

"my memory loss will last several minutes after treatment."

a nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

Assist the client to practice social interaction with peers during a community meeting

a nurse is contributing to the plan of care for a client who has a prescription for electroconvulsive therapy (ECT). Which of the following medications should the nurse prepare to administer prior to the treatment?

Atropine

The nurse working on an inpatient psychiatric unit admits a client diagnosed with antisocial personality disorder. After obtaining admission data from the client, the nurse plans care to include: (Select all that apply.) Careful monitoring of the new client's interaction with others on the unit. Consistency in staff assigned to care for this client. Strict limit-setting, with the rules carefully explained and written for the client. Involvement in group therapy. Encouraging socialization with other clients on the unit

Careful monitoring of the new client's interaction with others on the unit. Consistency in staff assigned to care for this client. Strict limit-setting, with the rules carefully explained and written for the client.

A nurse is reinforcing teaching with a group of adolescents regrading identifying behavioral indicators of depression. Which of the following manifestations should the nurse include? (select all that apply)

Decreased energy Isolation from peers Irritability

The nurse is caring for a client who has difficulty making decisions, frequently saying "I'm so stupid. What do you think I should do?" The client's actions lead the nurse to suspect the possibility of what personality disorder? Paranoid Schizoid Dependent Avoidant

Dependent

The nurse is leading a discussion group when a client asks who determines what is mentally healthy and what is not. The nurse's best response explains that mental health and mental illness are defined: According to whatever the client believes is right. Differently as culture and society change attitudes. According to the definition in the dictionary. Essentially the same throughout the world.

Differently as culture and society change attitudes.

The nurse is caring for a client with major depressive disorder who was recently placed on a high-potency neuroleptic (antipsychotic) medication. The client has not been eating well, is starting to get dehydrated, and has a temperature of 101°F. The physician orders antibiotics. Six hours later, the nurse notice that the client's temperature has risen to 103°F, and the client has muscle rigidity, and a fluctuating blood pressure. The priority of action for the nurse is to: Continue the medications and perform more frequent assessments of the client. Discontinue neuroleptic and report symptoms to physician immediately. Discontinue the neuroleptic and document assessment findings as cause for the action. Chart the assessment findings and report them to the primary nurse at change of shift.

Discontinue neuroleptic and report symptoms to physician immediately.

A nurse is caring for a client who has psychiatric somatic symptom disorder. Which of the following actions should the nurse take?

Encourage the client to examine how this illness behavior affects his family

A nurse is reinforcing teaching with a client who is begin taking paroxetine. Which of the following statements by the client indicates an understanding of the teaching?

I might not feel like eating as much

The nurse is working on an inpatient psychiatric unit that uses milieu therapy. The nurse's role in this form of therapy is to: Avoid caring for the same client every day. Model normal behavior for the clients. Provide negative reinforcement for bad behavior. Provide verbal rewards for good behavior.

Model normal behavior for the clients.

The nurse is participating in secondary prevention of a mental disorder or disorders when they are? Providing drug abuse prevention lectures in the school Teaching money management to clients with mental disorders Performing depression screenings at the local mall Administering medications to relieve extrapyramidal side effects

Performing depression screenings at the local mall

A nurse is talking with a client who has borderline personality disorder. The client states she is lonely and thinks the other nurses avoid her, but is afraid to share this concern with other staff. Which of the following actions should the nurse take?

Role-play this situation so the client can gain confidence in expressing her feelings

A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report the provider?

Sodium 132 mEq/L

A nurse is reinforcing teaching with a client who is to start taking lithium carbonate. Which of the following dietary supplements should the nurse instruct the client to avoid?

St. John's Wort

The nurse screens all children for early symptoms of mental health disorders because: Disorders that are caught early are easier to cure. Symptoms are more obvious and easy to see in children because children are so honest about their feelings. People with mental disorders in childhood are more likely to become violent in later life. Untreated mental disorders can lead to move severe, difficult-to-treat, and debilitating mental disorders in later life.

Untreated mental disorders can lead to move severe, difficult-to-treat, and debilitating mental disorders in later life.

the nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findings should the nurse withhold the client's medications and notify the provider?

WBC count

A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following should information should the nurse include in the teaching?

You might experience some temporary memory loss after the procedure

A nurse is caring for four clients who are displaying these of defense mechanisms. Which of the following clients should the nurse identify as using maladaptive defense mechanisms?

a client who has multiple sclerosis stops taking her medication and says her diagnosis is wrong

A nurse is caring for a group of clients on a mental health unit. The nurse should identify that which of the following clients can exhibit manifestations that are barriers to communication?

a client who has schizophrenia

A nurse is participating in group therapy for clients who have major depressive disorder. Which of the following topics should the nurse include in the orientation phase of the group therapy?

confidentiality

A nurse is collecting data from a client who is taking bupropion. Which of the following findings indicates the medication is effective?

decrease in urge to smoke

A nurse is reinforcing teaching with a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions should the nurse take to demonstrate modeling a behavior intervention strategy?

demonstrating hand hygiene at appropriate times

A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and his own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next?

determine the benefits and consequences of respecting the client's medical decisions

A nurse is assisting with an admission assessment for a client who has vegetative signs of depression. Which of the following is an appropriate intervention to recommend including in the plan of care?

developing a structured routine for the client to follow

a nurse is caring for a client who has a spinal cord injury and is at risk for depression. Which of the following findings should the nurse identify as an indication that the client is developing depression?

difficulty concentrating

A nurse is reinforcing teaching with the parent of an adolescent who has amphetamine use disorder. Which of the following statements by the parent should the nurse identify as indicating an understanding of the teaching?

dilated pupils are a sign my child is using amphetamines

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse anticipate?

elevated blood pressure

A nurse is assisting with the admission of a client to an acute care mental health facility. Which of the following activities should the nurse plan for the working phase of this therapeutic relationship?

evaluate the client's progress toward meting his goals

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which the following behaviors is the client exhibiting?

grandiosity

A nurse is contributing to the plan of care for a client who has an anxiety disorder. Which of the following interventions should the nurse recommend be included in the plan?

help the client identify situations that trigger his anxiety

A nurse is collecting data from a client who has delirium, the nurse should identify which of the following conditions as a predisposing factor for delirium

hepatic failure

A nurse is reinforcing teaching with a client who has a new prescription of phenelzine. The nurse should instruct the client that eating foods containing tyramine can cause which of the following adverse reactions with this medication?

hypertensive crisis

A nurse is caring for a client who is experiencing acute anxiety. which of the following actions should the nurse take? (select all that apply)

identify the cause of the anxiety validate the clients feelings establish rapport with the client

A nurse is a community center is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect?

impulsive behaviors

A nurse at a mental health facility is discussing antidepressant medications with a newly licensed nurse, comparing selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Which of the following information should the nurse include about TCAs?

increased risk of cardiovascular adverse effects

A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe?

naloxone

A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse expect to administer?

naltrexone

A nurse on an inpatient a mental health unit is supervising a group of clients in the unit's day room. The nurse fails to respond to the escalating, aggressive behavior of a client who eventually becomes violent and injures another client. For which of the following is the nurse liable?

negligence

A nurse on a mental health unit is assisting with he plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care?

offer liquid supplements to the client

A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?

offer the client high-calorie foods and fluids frequently

A nurse is caring for a client who reports recent amphetamine use. Which of the following manifestations should the nurse expect?

paranoia

The nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following is an appropriate food choice for this client?

peanut butter sandwich

A nurse is collecting data from a newly admitted client who has major depressive disorder. Which of the following findings should the nurse expect?

psychomotor retardation

A nurse is caring for a client who has depression and a new prescription for bupropion. The nurse should collect data from the client regarding which of the following contraindications for taking bupropion?

recent head trauma

A nurse is collecting data from a client who has agoraphobia. The nurse should identify that which of the following situations will increase the client's anxiety?

treavling in an airplane

A nurse is collecting data from a client who is start taking amitriptyline for depression. Which of the following dietary supplements should the nurse instruct the client to avoid?

valerian

a nurse is reinforcing teaching with a client who has a prescription for lithium carbonate to treat bipolar disorder. Which of the following instructions should the nurse include?

wait up to 3 weeks too see the full effects of the medication

The nurse working in a pediatrician's office admits an 8-year-old child whose growth was within the 50th percentile until the past year, when his weight failed to increase. He is now in the 10th percentile for growth. The child's mother reports that he sleeps all the time and all he wants to do when he is awake is play on the computer. His grades have been slipping, and his mother reports he claims he doesn't feel well and can't go to school at least 2-3 times per week. The nurse assesses the child and asks him: "What is school like this year?" "Sounds like you're not doing well in school. Why is that?" "Are you feeling depressed?" "Do you like school?"

"What is school like this year?"

A nurse is reinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the following statements should the nurse take?

"you should listen to music when you feel stress"

A nurse is preparing to administer lithium 450 mg PO to a client who has bipolar disorder. Available is lithium 150 mg capsules. How many capsules should the nurse administer?

3

The nurse is assisting with the admission of a client who also has a note in their chart of a personality disorder. the nurse recognizes that persons with personality disorders may exhibit: (Select all that apply.) Difficulty relating to others Have rigid and inflexible behaviors Perceptions that are not like the way others interpret events or intentions Poor impulse control No impairment of functioning or distress for the individual

Difficulty relating to others Have rigid and inflexible behaviors Perceptions that are not like the way others interpret events or intentions Poor impulse control

A nurse is caring for a client who has depression. When the nurse the client to join an activity the client states, "What's the use?" Which of the following is an appropriate nursing intervention?

Tell the client that its time for the activity, and accompany her to the activity

A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

The client paces in the hallway during the day and most of the night

a nurse is reviewing the morning laboratory report for a client who has bipolar disorder and recently starting taking lithium. The client's current lithium level is 1.2 mEq/L. Which of the following action should the nurse plan to take?

administer the regular dose of lithium **normal lithium levels are 0.8-1.4 mEq/L

A nurse is caring for a client who has depressive disorder and declines electroconvulsive therapy (ECT) despite the provider's recommendation. Which of the following ethical principles is the nurse demonstrating by supporting the client's decision?

autonomy

A nurse is reinforcing dietary teaching for a client who is start taking a monoamine oxidase inhibitor (MAOI). Which of the following food choices should the nurse identify as having the highest tyramine content?

avocados

A nurse is collecting data from a client who is taking valproic acid for the treatment of bipolar disorder. The nurse should identify that which of the following findings is priority to report to the provider?

bleeding gums

A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?

incoherent speech

A nurse is contributing to the plan of care for a school-age child who has attention deficit hyperactivity disorder. Which of the following interventions should the nurse recommend?

instruct the child to apologize for behavior that negatively affects others

A nurse is caring for client whose spouse died in a traumatic accident. Which of the following findings should the nurse manager identify as an indication of clinical depression?

persistent dysphoria

A nurse is caring for an adolescent on an inpatient mental health unit who is undergoing detoxification for a substance use disorder. He tell the nurse that he first began using illicit drugs when his parents wouldn't allow him to get a tattoo. Which of the following defense mechanisms is the client demonstrating?

projection

A nurse in an acute care mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following is the nurse's priority intervention?

protect the client and others from impulsive behavior

The nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take?

reinforce how to use assertive communication techniques

The nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take when caring for this client?

reminds he client of consequences for unacceptable behavior

A nurse is assisting with the plan of care for a client who is malnourished due to alcohol use disorder. Which of the following interventions should the nurse include in the plan

restrict the clients sodium intake

The nurse is collecting data from client who has just begun therapy with alprazolam to treat anxiety. The nurse should observe the client for which of the following adverse effects of this medications?

sedation

A nurse is caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse report to the charge nurse?

A client who is manic has been pacing the unit for several hours

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

significant change in weight

A nurse is preparing to assist with the care of a client who is to undergo electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment?

EEG monitor O2 state monitor ECG monitor

A nurse is reinforcing teaching with a client who has a new prescription for lithium carbonate to treat bipolar disorder. The nurse should make sure the client understands that he must maintain consistency in his intake of which of the following dietary elements?

sodium

The nurse working with a group of clients assesses which of the following as being mentally healthy? Select all that apply. (Select all that apply.) The client who believes her dead mother is in heaven watching what she does The client who lives with his mother, drinks beer all day, and has never held a job The client who is extremely angry at his ex-wife, and avoids contact with her when the children are around The client who works as a nurse and washes his hands frequently to prevent the spread of infection The client who says he dislikes people and prefers to be alone rather than socializing with others

The client who lives with his mother, drinks beer all day, and has never held a job The client who says he dislikes people and prefers to be alone rather than socializing with others

a nurse is contributing to the plan of care for a newly-admitted client who has severe depressive disorder. Which of the following interventions should the nurse include in the plan?

spend time with the client

A nurse is reinforcing teaching with a client about a new prescription for lithium. Which of the following statements should the nurse include in the teaching?

We will need to check you lithium levels in the next 3 to 5 days

A nurse is reinforcing teaching with a client who has major depressive disorder and a new prescription for fluoxetine. Which of the following statements should the nurse make to the client?

You could experience withdrawal manifestations if you stop taking fluoxetine abruptly

A nurse is collecting data from a group of clients who have depressive disorders. Which of the following findings should the nurse expect?

a lack of energy

A nurse is caring for a client who is undergoing outpatient electroconvulsive therapy (ECT) to threat rapid-cycling bipolar disorder. Following the procedure, which of the following actions should the nurse take?

administer oxygen to the client

A nurse is reinforcing teaching with a client who is to start taking lithium for bipolar disorder. Which of the following instructions should the nurse include?

take lithium with meals or a glass of milk

a nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

remain with the client

A nurse is collecting data from a client who has a history of cocaine use. Which of the following manifestations is an indication that the client is experiencing cocaine toxicity?

seizures

A nurse l an urgent care clinic is caring for a client who is using loud rapid speech, and continuously repeats, "I don't know why my wife left me." Which of the following levels of anxiety is the client experiencing?

severe

A nurse is caring for a client who has schizophrenia and a prescription for haloperidol. The nurse should identify that which of the following findings indicates a potential need for a PRN dose of beztropine?

shuffling gait

A nurse is collecting data from a client who is experiencing severe anxiety. Which of the following manifestations should the nurse expect?

sighing

a nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the dayroom and begins throwing objects at staff and other clients. After calling for assistance, which of the following actions should the nurse take next?

tell the client calmly to sit down

A nurse is caring for a client who is has an anxiety disorder and who has begin to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first?

tell the client you will remain with her

A nurse is collecting data from a client who is experiencing moderate anxiety, Which of the following findings should the nurse expect?

the client has a narrowed focus of attention

A nurse is caring for a client who is undergoing behavioral therapy for post traumatic stress disorder (PTSD). The nurse should identify that which of the following findings indicates improvement in the client's condition

the client reports about techniques she uses to promote sleep

A nurse is collecting data from a client who has dementia and whose family expresses concern about his increasing "memory problems." Which of the following findings should the nurse identify as the priority?

the client sometimes wanders from the house

A nurse on mental health unit is caring for four clients who have schizophrenia. Which of the following clients should the nurse see first?

the client who is experiencing command hallucinations

A nurse is contributing to the plan of care for a client who has antisocial personality disorder. Which of the following short-term goals should the nurse recommend be included in the plan?

the client will discuss feelings that cause hostility

a nurse is reinforcing teaching with a client who takes lithium carbonate for bipolar disorder. For which of the following findings should the nurse monitor as an adverse effect of the lithium carbonate?

thyroid enlargement

A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findings should the nurse identify manifestations of bulimia nervosa?

tooth erosion hand calluses hypokalemia

a nurse on an acute mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

walk with the client at a gradually slowing pace

A nurse is reinforcing discharge teaching for a client who will continue to take lithium carbonate at home to manage bipolar disorder. Which of the following instructions should the nurse include when reinforcing the teaching?

withhold the dose if having a find hand tremor