RN Mental Health Final Prep

Levels of anxiety

mild, moderate, severe, panic

Somatic symptom illness

multiple physical symptoms—combination of pain, GI, sexual, pseudoneurologic symptoms; no demonstrable organic basis

A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification? "I have heard that abusers try to keep their partner isolated from others." "I know that abusers lack social supports and social skills." "I know that men who are abusers gain power through intimidation." "I have heard that abusers think of themselves as important and have high self esteem."

"I have heard that abusers think of themselves as important and have high self esteem."

A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make? "It will help you feel better if you talk about it." "I'll come back when you feel like talking." "I'll stay with you a few minutes." "Coming with me to the day room will take your mind off your troubles."

"I'll stay with you a few minutes."

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 will be better for you to keep busy to avoid thinking about your child's death." "You will complete the grieving process about a year after your child's death." "The grief process will start once your child actually dies." "It is not uncommon to feel angry toward yourself or others."

"It is not uncommon to feel angry toward yourself or others."

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? "This morning, this morning, this morning..." "It was good. The Queen of England visited me there." "I just don't remember what I did this morning." "Snip, snap. Take a nap."

"It was good. The Queen of England visited me there."

A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements indicates an understanding of this disorder? "Postpartum depression usually begins 48 hours after childbirth." "It's common for clients who have postpartum depression to exhibit psychotic behavior." "The most common manifestation of postpartum depression is harming the infant." "Postpartum depression is most often seen in women who have history

"It's common for clients who have postpartum depression to exhibit psychotic behavior."

A client who is having burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make? "That's a hurtful thing to say." "Tell me more about that." "Why would you say such a thing?" "Well, that's your opinion."

"Tell me more about that."

Self-Injury

(also known as self-abuse, self directed aggression, self harm, self-inflicted mutilation) A injury done to onself w/o the aid of another person and the injury is severe enough for tissue damage

Perpetrator Characteristic

-Childhood abuse -Poor coping skills -Low self-esteem -Use of treats to control -Extreme disciplinarian who uses physical punishment -Violent outbursts

ASD/PTSD expected findings

-Intrusive findings (flashbacks, dreams) -memories are involuntary and cause distress -avoidance of people, places, situations that bring back memories -attempts to avoid thinking about event -mood and cognitive alterations -anxiety/depression -anger, irritability -decreased interest in current activities -guilt, negative self-beliefs, and cognitive distortions -detachment from others -inability to experience positive emotional experiences -dissociative manifestations (amnesia, derealization, depersonalization)

Types of Delusions

-Persecutory (or Paranoid), of Grandeur, of Reference, of control or influence, somatic delusion, delusions of thought broadcasting, delusions of thought insertion (or ideas of influence)

Bipolar comorbidities

-Substance use d/o -Anxiety d/o -borderline personality d/o -oppositional deviant d/o -Social phobia and specific phobias -ADHD -Migraines -Metabolic syndrome

Cognitive findings in schizophrenia

-disordered thinking -inability to make decisions -poor problem solving ability -difficulty concentrating to perform tasks -short term memory defecits -impaired abstract thinking Affective Findings: -hopelessness -suicidal ideations -unstable or rapidly changing mood Alterations in thout (delusions): -ideas of reference -persecution -grandeur -somatic delusions -jealousy -being controlled -thought broadcasting -thought inserting -thought withdrawl -religiosity -magical thinking Alterations in speech: -associative looseness -neologisms -echolalia -chang associations -word salad

nurse is preparing to administer haloperidol 5 mg IM to a client. The amount available is haloperidol 20 mg/mL. How many mL should the nurse administer?

0.25 mL

Kubler-Ross five stages of grief

1. Denial- client has difficulty believing a terminal dx or loss 2. Anger- anger is directed toward self, others, or objects 3. Bargaining- the client negotiates for more time or a cure 4. Depression- The client is overwhelmingly saddened by the inability to change the situation 5. Acceptance- the client accepts what is happening and plans for the future

A nurse is preparing to administer diazepam 7.5 MG 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 10th. Using a leading zero if it applies. Do not use a trailing zero.)

1.5

Survival rate of Alzheimer's disease

10 years, depending on other health conditions

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number)

14 mL 110 lb x (1 kg/2.2 lb) = 50 kg 50 kg x 0.55 mg = 27.5 mg 27.5 mg x(5 mL/10 mg) = 14 mL

A nurse is caring for a cleint who has schizophrenia and is experiencing hallucinations. The provider prescribes chlorpromazine 50 mg Im every 4 hr as needed. Available is chlorpromazine injection 25 mg/mL. How many mL should the nurse administer per dose?

2 mL

A nurse is caring for a client who has GAD and is experiencing severe anxiety. Which of the following stmts actions should the nurse make? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease your anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

A

A nurse is caring for a client who has a new Rx for disulfiram for the tx of alcohol use d/o. The nurse informs the client that this med can cause N/V when alcohol is consumed. Which of the following types of tx is this method an example? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectal behavior therapy

A

A nurse is caring for a client who has avoidant personality d/o. Which of the following stmts is expected from a client who has this type of personality d/o? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you let me smoke" C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myuself."

A

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? A. "Stop screaming, and walk with me outside." B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming." D. "What was going through your mind when you started screaming?"

A

A nurse is communicationg with a client who was admitted for treatment of a sustance use d/o. Which of the following comminication techniques should the nurse identify as a varrier to therapeutic comminication? A. Offering advise B. Reflecting C. Listening attentively D. Giving information

A

A nurse is discussing the care of a client following a sexual assault w/ a newly licensed nurse. Which of the following stmts by the newly licensed nurse indicates an understanding of teaching? A. "I will admin prophylactic tx for STI, like chlamydia." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar d/o." D. "I should use narrative documentation when documenting subjective data."

A

A nurse is planning care for a client who has body dysmorphic d/o. Which of the following actions should the nurse plan to take first? A. Assess the client's risk for self-harm B. Instill hope for positive outcomes C. Encourage the client to participate in group therapy sessions D. Assist the client to participate in treatment decisions

A

A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the POC? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Est boundaries

A

A nurse is preparing an educational seminar on stress for the other nursing staff. Which of the following info should the nurse include in the discussion? A. Excessive stressors cause the client to experience distress B. The body's initial adaptive response to stress is denial C. Absence of stressors results in homeostasis D. Negative, rather than positive, stressors produce a biological response

A

A nurse is reviewing the med record of a client who has conversion d/o. Which of the following findings should the nurse identify as placing the client at risk for conversion d/o? A. Death of a child 2 mos ago B. Recent wt loss of 30 lbs C. Retirement 1 yr ago D. Hx of migraine HA

A

A nurse is teaching a client about stress-reduction techniques. Which of the following client stmts indicates an understandin of the teaching? A. "Cognitive reframing will help me change my irrational thoughts to something positive." B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate." C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety." D. "mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

A

A nurse is discussing normal grief w/ a client who recently lost a child. Which of the following stmts made by the client indicates understanding? (SATA) A. "I may experience feelings of resentment." B. "I will probably withdrawal from others." C. "I can expect to experience changes in sleep." D. "It is possible that I will experience suicidal thoughts." E. "It is experienced that I will have a loss of self-esteem,"

A B C

A nurse is preparing to implement cognitive regraming techniques for a client who has an anxiety d/o. Which of the following techniques should the nurse include in the POC? (SATA) A.. Priority restructuring B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation

A B D

A nurse is working w/ a client who recently lost a guardian. The nurse recongizes that which of the following factors influence a client's grief and coping ability? (SATA) A. Interpersonal relationships B. Culture C. Birth Order D. Religious beliefs E. Prior experience w/ loss

A B D E

A nurse is discussing the factors for somatic symptom d/o w/ a newly licensed nurse. WHich of the following risk factors should the nurse include? (SATA) A. Age older than 65 years B. Anxiety d/o C. Childhood trauma D. Coronary artery disease E. Obesity

A C

A nurse is caring for a client who has substance-induced psychotic d/o and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following stmts should the nurse make? (SATA) A. "When did your start hearing these things?" B. "The voices are not real, or else we would both hear them" C. "It must be scary to hear voices." D. "Are the voices you hear telling you to hurt yourself?" E. "Why are the voices talking to only you?"

A C D

A nurse working on an acute mental health unit is caring for a client who has PTSD. Which of the following findings should the nurse expect? (SATA) A. Difficulty concentrating on tasks B. Obsessive need to talk about the traumatic event C. Negative self-image D. Recurring nightmares E. Diminished reflexes

A C D

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive sx? (SATA) A. Auditory hallucinations B. Lack of motivation C. Use of clang association D. Delusions of persecution E. Constantly waving arms F. Flat affect

A C D E

A charge nurse is preparing a staff education session on personality d/o. Which of the following personality characteristics associated w/ all of the personality d/o should the charge nurse include in the teaching? (SATA) A. Difficulty in getting along w/ other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to be more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship w/ staff

A C E

A nurse is obtaining a nursing hx from a client who has a new dx of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (SATA) A. "What is your relationship like w/ your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about your appearance?"

A C E

A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? (SATA) A. Install extra locks at the top of exit doors B. Place rugs over electrical cords C. Put cleaning supplies on the top of a shelf D. Place the client's mattress on the floor E. Install light fixtures above the stairs

A D E

A nurse is assessing a client who has generalized anxiety d/o. Which of the following findings should the nurse expect? (SATA) A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Sleep disturbance

A D E

A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (SATA) A. Voice changes B. Seizure activity C. Disorientation D. Cough E. Neck pain

A D E

A nurse is caring for four clients in the emergency department. The nurse should identify that which of the following clients can give informed consent?

A 35-year-old client who has major depressive disorder

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? A client refuses electroconvulsive therapy after signing the consent form. A client who was voluntarily admitted left the unit against medical advice. A client was administered one-half of the prescribed dose of medication. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed.

A client was administered one-half of the prescribed dose of medication.

A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? A client who has a fasting blood glucose level of 80 mg/dL A client who has a sodium level of 128 mEq/L A client who has a BUN of 18 mg/dL A client who has a potassium level of 3.6 mEq/L

A client who has a sodium level of 128 mEq/L

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. A client who has depression reports having a lack of interest in assisting their partner in the care of their children. A client who has borderline personality disorder threatened to harm their roommate. An adolescent client who has anorexia nervosa has a BMI of 17.

A client who has borderline personality disorder threatened to harm their roommate.

A nurse on an acute mental health facility is receiving change of shift report for four clients. Which of the following should the nurse assess first?

A client who is experiencing delusions of persecution.

A nurse is receiving change of shift report for four clients. Which of the following should the nurse plan to see first?

A client who is taking clozapine and reports a sore throat and chills

Noncompliance

A conscious set of behaviors associated w/ not following recommended health care activities, such as not taking physician-ordered meds (reasons for noncompliance vary but could be related to: being asymptomatic, not being able to afford tx; not understanding the need for tx, minimizing the seriousness of the problem, or a way of reasserting control.)

Dissoc

A disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalization of uncomfortable or unpleasant aspects of oneself

1:1 interaction

A nurse-client interaction that involves one nurse and one clientd

MDD (major depressive disorder)

A single episode or recurrent episodes of unipolar depression resulting in significant change in a client's normal functioning accompanied by at least 5 of the following specific findings, which must occur almost daily for a min of 2 weeks, and last most of the day: -depressed mood -difficulty sleeping or excessive sleeping -indecisiveness -decreased ability to concentrate -suicidal ideation -increase or decrease in motor activity -inability to feel pressure -increase or decrease in wt of more than 5% of total body weight in over 1 month

A nurse is preparing to discharge an older adult who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply." A. Occupational therapy B. Meal delivery services C. Speech therapy D. Physical therapy E. Home health services

A, B, D, E An occupational therapist can assist the client to perform ADLs. Meal deliver services are necessary due to the client's difficulty performing ADLs. A physical therapist can assess the client's mobility needs and assist with ADLs. Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs.

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? A. Dysrhythmias B. Cataracts C. Pancreatitis D. Bleeding

A. Dysrhythmias

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? A. Emotional lability B. Self-sacrificing C. Suspicious of others D. Graniosity

A. Emotional lability Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances.

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to drink 125 mL of fluid each hour while awake. B. Allow the client to eat independently in his room. C. Weigh the client twice weekly. D. Measure the client's vital signs once each day.

A. Encourage the client to drink 125 mL of fluid each hour while awake. The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration.

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity? A. Experiencing diarrhea B. Exercising moderately C. Increasing sodium intake D. Drinking green tea

A. Experiencing diarrhea

A nurse is caring for a client who has just begun therapy with alprazolam to treat anxiety. The nurse should monitor the client for which of the following adverse effects of this medication? A. Insomnia B. Bradycardia C. Hearing loss D. Hypertension

A. Insomnia

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "That man in my room never sleeps and he keeps me up too." Which of the following is an appropriate action for the nurse to take? A. Move the client who has bipolar disorder to a private room. B. Administer sleep medication to the client who has bipolar disorder. C. Move the client who has severe depression to a private room. D. Administer sleep medication to the client who has severe depression.

A. Move the client who has bipolar disorder to a private room. Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room.

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? A. Paroxetine B. Lithium C. Donepezil D. Valproate E. Carbamazepine

A. Paroxetine B. Lithium D. Valproate E. Carbamazepine

A nurse is creating a plan for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply) A. Provide immediate verbal feedback for escalating behavior. B. Maintain an environment with low stimuli. C. Monitor vital signs every 1 to 2 hr throughout the day. D. Discourage the client from taking a nap during the day. E. Weigh client every 3 to 4 days.

A. Provide immediate verbal feedback for escalating behavior. B. Maintain an environment with low stimuli. C. Monitor vital signs every 1 to 2 hr throughout the day.

Negative sx of Schizophrenia

Absence of things that are normally present: Affect is blunted -Alogia; poverty of thought or speech, might sit w/ a visitor but only mumble or respond vaguely -Anergia: lack of energy -Anhedonia -Avolition: lack of motivation in activities and hygiene

Maturational/internal crisis

Achieving new developmental stages, which requires learning additional coping mechanisms, such as marriage or retiring

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benzotropine To relieve which of the following adverse effects?

Acute dystonia

Care of client w/ MDD

Acute phase: severe clinical findings of depression -tx is generally 6-12 weeks in duration -potential need for hospitalization -reduction of depressive manifestations is the goal of tx -assess suicide risk, and implement safety precautions or one-to-one observation as needed Continuation phase: increased ability to function -tx is generally 4-9 mos in duration -relapse prevention through education, medication therapy, and psychotherapy is the goal Maintenance phase: remission of manifestations -this phase can last for years -prevention of future depressive episodes is the goal

To control early EPS

Administer anticholinergics, beta-blockers, and benzodiazepines

int A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? Allow the client time to formulate an answer. Prompt the client to give a response. Move on to the next client. Offer the client a suggestion for a goal.

Allow the client time to formulate an answer.

Defense Mechanisms

Altruism, Sublimination, Supression, Repression, Displacement, Reaction formation, Undoing, Rationalization, Dissociation, Denial, Compensation, Identification, Intellectualization, Conversion, Splitting, Projection

Angry or aggressive patients

Always attempt to get to the root of the problem

Meds for ASD & PTSD

Antidepressants can decrease depression and relieve anxiety - paroxetine/sertraline- SSRI; Venlafaxine- SNRI; Mirtazapine- norepinephrine and serotonin specific antidepressant; Anitriptyline- Tricyclic antidepressant; Prazosin- centrally acting alpha agonist can decrease manifestations of hypervigilance and insomnia; Propanolol- beta-adrenergic blocker decreases elevated VS and manifestations of anxiety, panic, hypervigilance, and insomnia

emotion that is congruent w/ the situation

Appropriate affect

How can a nurse provide culturally competent care?

Ask the pt!!!

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

Assist the client with deep breathing exercises.

A nurse in a mental health facility is planning discharge for a client who has a 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 their parent, who has promised to keep them away from alcohol

Attending a relapse prevention group several times each week

A nurse is caring for a client within the intimate zone of the client's personal of the following activities in this space? (Select all that apply.) The nurse should perform which Auscultating heart sounds Teaching about a medication Changing a dressing Discussing intake and output Talking with partner

Auscultating heart sounds Changing a dressing

A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.) Avoid wearing necklaces during client care. Know the layout of the facility. Stand directly in front of the client when talking. Bring security with you for all client interactions. Provide immediate verbal feedback for escalating behavior.

Avoid wearing necklaces during client care. Know the layout of the facility. Provide immediate verbal feedback for escalating behavior.

Orientation

Awareness of: 1) time 2) place 3) person, and 4) circumstance or situation

A community health nurse is leading a discussion about rape w/ a neighborhood task force. Which of the following statements by the neighborhood citizen indicates an understanding of teaching:? A. "Rape is a crime of passion." B. "Acquaintance rape often involves alcohol." C. "Young adults are the typical victims of sexual assault." D. "The majority of rapists are unknown to the victims."

B

A nurse decides to put a cleint who has a psychotic d/o in seclusion overnight because the unit is very short staffed, and the client frequently fights w/ the other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery

B

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care w/ social services B. Identify the client's perception of their mental health status C. Include the client's family in the interview D. Teach the client about their current mental health d/o

B

A nurse is assessing a 4 y/o child for indications of autism spectrum d/o. For which of the following manifestations should the nurse assess? A. Impulsive behavior B. Repetitive counting C. Destructivenss D. Somatic problems

B

A nurse is caring for a broup of clients. Which of the following clients should a nurse consider a referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for scheduled monthly antipsychotic inj for schizophrenia C. A client in a day treatment program who reports increasing anxiety during group therapy D. A client in a weekly grief support group who reports missing a deceased partner who has been dead x 3 months

B

A nurse is caring for a client who has early stage Alzheimer's disease and a new Rx for donepezil. The nurse should include which of the following statements when teaching the client about the med? A. "You should avoid taking over-the-counter acetaminophen while on donepezil." B. "ou should take this med before going to bed at the end of the day." C. "You will be screened for underlying kidney disease prior to starting donepezil." D. "You should stop taking donepezil if you experience nausea or diarrhea."

B

A nurse is caring for a client with borderline personality d/o. The client says, " The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? A. Regression B. Splitting C. Undoing D. Identification

B

A nurse is caring for a clint wgi gas schizoaffective d/o. Which of the following stmts indicates the client is experiencing depersonaliation? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monstors pinching me all over." D. "I know that you are stealing my thoughts."

B

A nurse is conducting a family therapy session. The younger child tells the nurse aout plans to make the older sibling look bad, believing this will earn more freedom and privleges. The nurse should identify this disfynctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction

B

A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a resp rate of 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate. C. Severe. D. Panic

B

A nurse is reviewing the medical records of multiple clients at a community mental health facility. Which of the following events is an example of a client experiencing a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

B

A nurse is talking w/ a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live w/ him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A. Learn to practice mindfulness B. Use assertiveness techniques C. Exercise regularly D. Rely on the support of a close friend

B

A nurse is teaching a client who has an anxiety d/o and is scheduled to begin classical psychoanalysis. Which of the following client stmts indicate an understanding of this form of therapy? A. "Even if my anxiety inproves, I will need to continue this therapy for 6 weeks." B. "The therapist will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviours." D. "This type of therapy will address my conscious feelings about stressful experiences."

B

A nurse is caring for a client who has major depressive d/o. Which of the following should the nurse identify as a risk factor for depression? (SATA) A. Male sex B. Hx of chronic bronchitis C. Recent death in pt family D. Family Hx of depression E. Personal Hx of panic d/o

B C D E

A nurse is discussing acute vs. prolonged stress w/ a client. Which of the following effects should the nurse identify as an acute stress response? (SATA) A. Chronic pain B. Depressed immune system. C. Increased BP D. Panic attacks E. Unhappiness

B C E

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary info to the client? (SATA) A. Reassure the client that everything will be ok B. Discuss prior use of coping mechanisms w/ the client C. Ignore the client's anxiety so that she will not be embarrassed D. Demonstrate a calm manner while using simple and clear directions. E. Gather info from the client using closed-ended questions

B D

A nurse is discussing relapse prevention w/ a client who has bipolar d/o. Which of the following information should the nurse include in the teaching? (SATA) A. Use caffeine in moderation to prevent relapse B. Difficulty sleeping can indicate a relapse C. Begin taking your medications as soon as a relapse begins D. PArticipating in psychotherapy can help prevent a relapse E. Anhedonia is a clinical manifestation of a depressive relapse

B D E

A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the client's ability to cope with this situation? A. "Don't you think you'll get through this in time?" B. "To whom do you talk when you feel overwhelmed?" C. "Have you thought about rebuilding your home on the same site?" D. "Would you like me to find a therapist for you to speak with?"

B. "To whom do you talk when you feel overwhelmed?" By asking this question, the nurse is assessing the client's support systems, which is an important factor in the client's ability to cope with the situation.

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? A. "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." C. "You don't want to look at yourself because you think you are fat." D. "You and I can work together to overcome your fears of gaining weight."

B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.

A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? A. A client who has a fasting blood sugar of 80 mg/dL B. A client who has a sodium level of 128 mEq/L C. A client who has a BUN of 18 mg/dL D. A client who has a potassium level of 3.6 mEq/L.

B. A client who has a sodium level of 128 mEq/L A sodium level of 128 mEq/L should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level.

A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take? A. Prepare for gastric lavage due to an extremely elevated lithium level. B. Administer the morning dose of lithium. C. Check the client's medication record to assess whether the client has been refusing her lithium. D. Hold the medication and assess for early manifestations of toxicity.

B. Administer the morning dose of lithium.

A nurse is teaching a class about safe medication administration. The nurse should include in the teaching that which of the following references are acceptable for safe medication administration? (Select all that apply) A. A website that ends in .com B. Published journals C. Pharmacists D. Physicians' Desk Reference E. Pharmaceutical sales representatives

B. Published journals C. Pharmacists D. Physicians' Desk Reference

A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The client's current mood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following? A. A blood lithium level of 1.8 mEq/L is not within the maintenance treatment level. B. The lithium level is at the toxic level. C. The lithium level is below the therapeutic treatment level. D. The lithium level is within the therapeutic level for initial treatment.

B. The lithium level is at the toxic level.

Secondary gains

Benefits of being treated for illness, including the ability to rest, to be freed from unpleasant tasks, and to be taken care of by others.

A charge nurse is discussing the care of a client who has MDD w/ a newly licensed nurse. Which of the following stmts by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The tx of MDD during the maintenance phase lasts for 6-12 weeks" C. " The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Meds and psychotherapy are most effective during the acute phase of MDD."

C

A nurse is caring for a client in an inpt mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express feelings out loud B. Maintain eye contact w/ the client C. Move the client away from others D. Tell the client that the behavior is not acceptable

C

A nurse is caring for a client who has alcohol use d/o. The client is not longer exp withdrawal manifestations. Which of the following meds should the nurse anticipate admin to assist the client w/ maintaining abstinence from alcohol? A. Chlordiazepoxide B. Bupropion C. Disulfiram D. Carbamazepine

C

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you might have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that it is important to you. "

C

A nurse is caring for a client who has derealization d/o. Which of the following findings should the nurse identify as an indication of derealization? A. The client describes a feeling of floating above the ground B. The client has suspicions of being targeted in order to be robbed and killed. C. The client states that the furniture in the room seems to be small and far away D. The client cannot recall anything that happened during the past 2 weeks

C

A nurse is counseling several clients. Which of the following client stmts should the nurse identify as expected for factitious d/o imposed on another? A. "I had to pretend I was injured in order to get disability benefits" B. "I know that my abd pain is caused by a malignant tumor." C. "I needed to make my child sick so that someone else would take care of them for a while." D. "I became deaf when i heard that my partner was having an affair w/ my best friend."

C

A nurse is interviewing a client who has a new dx of persistent depressive disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of a minimum of 5 clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self-esteem

C

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? A. Orient the client frequently to time, place and person B. Offer fluids and nourishing diet as tolerated. C. Implement seizure precautions D. Encourage participation in group therapy sessions

C

A nurse is talking w/ a client who is at risk for suicide following their partner's death. Which of the following stmts should the nurse make? A." I feel very sorry for the loneliness you must be experiencing." B. "Suicide is not the appropriate way to cope w/ loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose a loved one."

C

A nurse is teaching a client who has a new dx of premenstrual dysphoric d/o (PMDD). Which of the following stmts by the client indicates an understanding of the teaching? A. "I can expect my problems w/ PMDD to be worse when I'm menstruating." B. "I should avoid exercising when I am feeling depressed" C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake w/ a nurtritional supplement when my PMDD is active"

C

A nurse is teaching a newly licensed nurse about the use of ECT for the tx of bipolar d/o. Which of the following stmts by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial tx for bipolar d/o." B. "ECT is contraindicated for clients who have suicidal ideations." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar d/o."

C

A nurse is working w/ an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? A, A member who praises input from other members B. A member who follows the direction of other members C. A member who brags about accomplishments D. A member who evaluates the group's performance toward a standard

C

A nurse wants to use democratic leadership w/ a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when demonstrating which of the following actions? A. Observes group techniques w/o interfering w/ the group process B. Discusses a technique and then directs members to practice the technique C. Asks for the group suggestions of techniques then supports discussion D. Suggests techniques and asks group members to reflect on their use

C

A nurse is assisting the guardians of a school-aged chjild who has oppositiional defiant d/o in identifying strategies to promote positive behavior. Which of the following strategies should the nurse recommend? (SATA) A. Allow the child to choose which behaviors are unacceptable B. Use role-playing to act out unacceptable behavior C. Develop a reward system for acceptable behaviors D. Encourage the child to participate in school sports E. Be consistent when addressing unacceptable behavior

C D E

A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching? A. "I will take my dose of orlistat every morning an hour before breakfast." B. "I will eat a no-fat diet to prevent side effects from the medication." C. "I will stop taking orlistat and call my doctor if my urine gets darker in color." D. "I will feel less hungry during meals while I am taking orlistat."

C. "I will stop taking orlistat and call my doctor if my urine gets darker in color."

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use the same plan of care and interventions for each client who has depression." B. "Each individual nurse will develop a separate plan of care when managing clients who have depression." C. "I will update the plan of care as a client's manifestations of depression change." D. "An assistive personnel can use the plan of care for client teaching."

C. "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change.

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? A. Delusions B. Neologisms C. Anhedonia D. Echopraxia

C. Anhedonia Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.

A nurse in a community health center is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? A. Repeatedly talks about traumatic incident B. Sleeps excessively C. Experiences feelings of isolation D. Uses repetitive speech

C. Experiences feelings of isolation Clients who have PTSD often feel estranged and detached from others.

A nurse in a mental health clinic is caring for a client with bipolar disorder and reports that she stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? A. Sore throat B. Photophobia C. Hand tremors D. Constipation

C. Hand tremors Fine hand tremors are an expected adverse effect of lithium and can interfere with the client's ADLs, causing the client to stop taking the medication.

A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should included in the plan of care? A. Allow manipulation so as to not raise the client's anxiety. B. Avoid discussing past behaviors with the client. C. Institute consequences for manipulative behavior. D. Bargain with the client to discourage manipulative behavior.

C. Institute consequences for manipulative behavior.

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to participate in group therapy. B. Instruct the client to avoid napping during the day. C. Offer the client high-calorie finger foods frequently. D. Decrease the client's daily fiber intake.

C. Offer the client high-calorie finger foods frequently. The nurse should frequently offer the client, high-calorie foods that can be eaten while the client is on the go. Client's experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? A. An adolescent family member who questions parental authority. B. A family with three generations in the same household. C. Older children who are responsible for their younger siblings. D. Two adults and their children from prior relationships in the same household.

C. Older children who are responsible for their younger siblings. This is an example of enmeshed boundaries in which there are no distinctions between roles of family members.

A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse take? A. Encourage the parent to avoid discussing the death with other children in order to protect their feelings. B. Recommend each parent grieve in private to avoid hindering each other's healing. C. Suggest forming a weekly support group for parents who have experienced the loss of a child. D. Advise the parents to begin counseling if they are still grieving in a few months.

C. Suggest forming a weekly support group for parents who have experienced the loss of a child. Support groups are a positive resource in the process of recovery for parents who have lost a child.

The nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? A. The client is married. B. The client recently received a promotion at work. C. The client has COPD. D. The client is a male.

C. The client has COPD. Clients who have a medical illness are at an increased risk for the development of depression.

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? A. The client has begun playing basketball with several other clients during the past month. B. The client identifies with problems expressed by other clients. C. The client's behavior has become impulsive in the past few weeks. D. The client states she wants to go home to be with her children and partner.

C. The client's behavior has become impulsive in the past few weeks.

A nurse on a mental health unit observes a client who has acute mania hit another client.Which of the following actions should the nurse take first?

Call for a team of staff members to help with the situation.

Borderline Personality Disorder (BPD)

Characterized by instability of affect, identity, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment; often self-injurious and potentially suicidal; ideas of reference are common

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care? Rotate staff assignments for this client. Use touch to calm the client during periods of anxiety. Check the client's mouth after the client takes medication. Assign an assistive personnel to feed the client at mealtimes.

Check the client's mouth after the client takes medication.

Medication slows progress of Alzheimer's disease

Cholinesterase inhibitor meds- Donepezil, Rivastigmine, Galantamine

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their 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 Word salad Neologism Echolalia

Clang association

A charge nurse on a mental health unit is discussing clients rights with a newly licensed nurse. Which of the following statements should the nurse make?

Clients who are admitted voluntarily maintain the right to give informed consent for procedures

Can be injected, smoked, or inhaled (snorted) Intended effects: rush of euphoria (extreme well-being) and pleasure, increased energy Effects of intoxication: Mild toxicity - dizziness, irritability, tremor, blurred vision Severe effects - hallucinations, seizures, extreme fever, tachycardia, HTN, chest pain, possible cardiovascular collapse and death

Cocaine Intoxication

Depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation, non life-threatening, but possible occurrence of suicidal ideation

Cocaine Withdrawal Manifestations

A nurse in a health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others?

Command hallucinations

A charge nurse is conducting a class on therapeutic communication w/ a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. Personal space B. Posture C. Eye contact E. Intonation

D

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a memeber of the group indicates an understanding of teaching? A. " Children older than 5 are at a greater risk for abuse." B. "Substance use d/o does not increase the risk for violence." C. "Entering an intimate relationship increases the risk for violence." D. "Pregnancy increases the risk for violence from a spouse or partner."

D

A nurse in a pediatric clinic is caring for a preschool-age child who has a new dx of ADHD. When teaching the guardian about this d/o, which of the following stmts should the nurse include in the teaching? A. "Behaviours associated w/ ADHD are present prior to age 3" B. "This d/o is characterized by argumentativeness" C. "Below-average intellectual functioning is associated w/ ADHD" D. "Because of this d/o, your child is at an increased risk for injury"

D

A nurse in an acute mental health facility is communicating w/ a client. The client states, "I can't sleep. I stay up all night". The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic comminication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

D

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the POC? A. Assign the client to a private room B. Document the client's behavior every hour C. Allow the client to keep perfume in her room. D. Ensure that the client swallows meds

D

A nurse is conducting a class for a group of newly licensed nurses on care for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat of suicide is attention-seeking behavior B. Interventions are ineffective for clients who really want to commit suicide. C. Using the term suicide increases the client's risk for suicide attempt. D. A no-suicide contract decreases the clients risk for suicide.

D

A nurse is discussing free association as a therapeutic tool w/ a client who has MDD. Which of the following client stmnts indicates an understanding of this technique? A. "I will write down my dreams as soon as I wake up" B. "I might begin to associate my therapist w/ important people in my life" C. "I can learn to express myself in a nonaggressive manner" D. "I should say the first thing that comes to my mind"

D

A nurse is planning care for a client who has anorexia nervosa w/ binge-eating and purging behavior. Which of the following actions should the nurse include in the client's POC? A. Allow the client to select preferred meal times B. Est consequences for purging behavior C. Provide the pt w/ a high-fat diet at the start of tx. D. Implement one-to-one observation during meal times

D

A nurse is planning care for a pt who has mental health d/o. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the pt w/ systematic desensitization therapy B. Teach the pt appropriate coping mechanisms. C. Assess the pt for comorbid health conditions D. Monitor the pt for adverse effects of meds

D

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? A. Slow onset B. Aphasia C. Confabulation D. Easily distracted

D. Easily distracted Extreme distractibility is a hallmark manifestation of delirium.

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take? A. Monitor the client closely to prevent self-mutilation. B. Set limits to prevent exploitation of other clients. C. Discourage flamboyant or seductive behaviors. D. Give positive feedback when client is assertive with staff or clients.

D. Give positive feedback when client is assertive with staff or clients.

A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety. Which of the following foods should the nurse advise the clients to avoid when taking their prescription? A. Carbonated beverage B. Milk C. Orange juice D. Grapefruit juice

D. Grapefruit juice

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A. Lansoprazole B. Naproxen C. Magnesium hydroxide D. Phenylephrine

D. Phenylephrine Clients who are taking tranylcypromine, an MAOI antidepressant, should not take Phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority? A. Encourage expression of feelings. B. Promote attendance at an assertiveness training group. C. Assist the client to perform relaxation breathing. D. Reduce environmental stimuli.

D. Reduce environmental stimuli. The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to use a therapeutic holding technique to deescalate the behavior and prevent injury.

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? A. Confront the staff member. B. Encourage the client to report the incident. C. Document the incident in the client's health record. D. Report the occurrence to the charge nurse.

D. Report the occurrence to the charge nurse. It is the charge nurse and the nurse manager's responsibility to confront the staff member about her behavior toward the client.

Sublimination (defense mechanism)

Dealing w/ unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression

Suicidal I

Direct or indirect thoughts or fantasies of suicide or self-injurious acts expressed verbally or through writing or artwork without definite intent or action expressed. May be veiled or expressed symbolically

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?

Early identification of changes, such as decrease social involvement, is important.

A nurse is performing a cognitive assessment to distinguish delirium from dementia and a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurses suspicion of delirium?

Easily distracted

an exaggerated feeling of well-being

Elevated (or elated) Mood

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? Encourage the client to drink 125 mL of fluid each hour while awake. Allow the client to eat independently in their room. Weigh the client twice weekly. Measure the client's vital signs once each day.

Encourage the client to drink 125 mL of fluid each hour while awake.

A nurse is planning prevention strategies for a partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

Establish screening programs to identify at risk clients.

A nurse in a community health centers teaching families of clients who have post traumatic stress disorder about expected clinical manifestations. Which of the following manifestation should the nurse include?

Experiences feelings of isolation

A feeling of remorse arising from a real or imagined offense

Feelings of guilt (feeling guilty)

Feelings or worthlessness

Feelings of having no value, dignity, worth or virtue (common w/ MDD)

Feelings of discouragement about the future( common w/ Major Depressive D/o and dysthymia)

Feelings of helplessness

Schizophrenia meds

First gen/conventional antipcychotics: -Haloperidol -Loxapine -Chlorpromazine -Fluphenazine ;Monitor for EPS, including dystonia, akathesia, pseudoparkinsonism, and tardive dyskinesia -client education: to minimize anticholinergic effects, chew sugarless gum, eat foods high in fiber, and eat and drink 2-3 L of fluid daily -indications of postural hypotension include: lightheadedness, dizziness Second Gen/atypical antipsychotics: -Risperdone -Olanzapine _Quetapine -Ziprasidone _Clozapine ;- pt education: to minimize wt gain, follow healthy, low-calorie diet, engate in regular exercise and monitor weight -adverse effects are agitation, dizziness, sedation and sleep disruption: report these to provider -blood tests are needed to monitor for agranulocytosis Third gen antipsychotics: -Aripiprazole ;-decreased risk of EPS's or tardive dyskenisia, lower risk for wt gain and anticholinergic effects Mood stabilizing agents and benzodiazepines: -Valproate _Lamotrigine -Lorazepam ;-use meds w/ caution in older adult clients

Events that place pt as risk for conversion d/o

First-degree relative who has conversion d/o -childhoold physical or sexual abuse -comorbid psychiatric conditions: depressive d/o, anxiety d/o, PTSD, personality d/o - comorbid medical or neurological condition - recent acute stressful event - female sex -adolescent or young adult -low socioeconomic status, low educational status

Medication to treat clients with Anorexia Nervosa and other eating disorders

Fluoxetine - SSRI Instruct client that med can take 1-3 wks for initial response, up to 2 months for maximal response Instruct client to avoid hazardous activities until individual adverse effects are known Instruct client to notify provider if sexual dysfunction occurs

Bipolar risk factors

Genetics: having an immediate family member who has bipolar d/o Psysiological: neurobiologic and neuroendocrine d/o Environment: Increase stressed in the environ can trigger mania and depression and increase risk for severe manifestations in genetically-susceptible children

A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, inability 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? Discourage rest periods during the daytime. Instruct family to avoid visiting during mealtimes. Offer three or four large meals daily. Give the client extra time to communicate needs.

Give the client extra time to communicate needs.

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?

Giving away possessions

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for one week. Which of the following outcome should the nurse expect?

Greater risk of attempting suicide as a fact and energy improve.

Disenfranchised grief

Grief over a loss that is not or cannot be openly acknowledged, mourned publicly, or supported socially (nurses or healthcare workers losing a pt)

A nurse in a community Health center is working with a group of clients who have posttraumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members?

Guided imagery

A false sensory preception, arising from any of the 5 senses, without external stimuli; a sensory perception that does not exist in reality

Hallucination

Antipsychotic First-Generation block dopamine, acetylcholine, histamine and norepinephrine in the brain and periphery. Inhibition of psychotic findings is believed to be a result of dopamine blockade in the brain.

Haloperidol (Haldol) - high potency

First-generation antipsychotics

Haloperidol, high potency Fluphenazine, high potency Loxapine, medium potency Perphenazine, medium potency Thiothixene, high potency Trifluoperazine, high potency

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? Sore throat Photophobia Hand tremors Constipation

Hand tremors

A nurse manager is planning a staff inservice on medical diagnoses that can mimic psychosis. Which of the following should the nurse manager include in the presentation? (Select all that apply.) Hypothyroidism Alzheimer's disease Hyperglycemia Encephalitis Parkinson's disease

Hypothyroidism

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 am unable to walk

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following intervention should the nurse include in the plan?

Identify the clients trigger foods

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statement should the nurse make?

It appears as though you would like to open the door.

A nurse is teaching the guardians of a client about their adolescent child diagnosis of bulimia nervosa Which of the following statements made by the guardians indicates an understanding of their child's illness?

It is important for our child to have regular dental check ups

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

Tx & interventions for abuse

Laws r/t domestic violence -arrest -restraining order/ civil orders of protection -shelters -individual psychotherapy/counseling, group therapy, support &self help groups -Treatment for anxiety & depression

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?

Let's talk about what is upsetting you

Mood stabilizer; select prototype medication produces neurochemical changes in the brain, including serotonin receptor blockade evidence that this med decreases neuronal atrophy and/or increases neuronal growth used to treat bipolar disorders controls episodes of acute mania, helps prevent the return of mania or depression, and decreases the incidence of suicide

Lithium Carbonate

Lithium contraindications/precautions

Lithium is a Pregnancy Risk Category D med. Considered teratogenic, especially during the first trimester of pregnancy Discourage clients from breastfeeding if lithium therapy is necessary Lithium is contraindicated in clients who have severe renal or cardiac disease, hypovolemia, and schizophrenia Use cautiously in older adult clients and clients with thyroid disease, seizure disorder, or diabetes

A charge nurse is preparing an educational session about addictive disorders for nursing staff. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply). Being female Low self-esteem Family history of addiction Personality disorders Asian ethnicity

Low self-esteem Family history of addiction Personality disorders

Indications for ECT

MDD, schizophrenia spectrum disorders, acute manic episodes

Complications of ECT

Memory loss, confusion, reactions to anesthesia, cardiovascular changes, headache, muscle soreness, nausea, relapse of depression

Compound rape reaction

Mental health disorders (depression or substance use disorder) Physical disorders (manifestations of a prior illness)

A Nurse is planning care for a client who has generalized anxiety disorder.Which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

Mild

A health life force that is necessary for survival, moticates people to take action

Normal Anxiety

Obsessive Compulsive Disorder

OCD, Hoarding d/o, Body dysmorphic d/o

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.) Offer finger foods to the client every 2 hr. Maintain an environment with low stimuli. Monitor vital signs every 1 to 2 hr throughout the day. Discourage the client from taking a nap during the day. Weigh client every 3 to 4 days.

Offer finger foods to the client every 2 hr. Maintain an environment with low stimuli. Monitor vital signs every 1 to 2 hr throughout the day.

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?

Offer the client high calorie finger foods frequently

ECT, TMS, VNS

Offers nonpharmacological tx for clients who have certain mental health d/o

A nurse is assessing a family dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?

Older children who are responsible for their younger siblings.

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

-hallucinations -delusions -alterations in speech bizarre behaviour (walking backward constantly)

Positive symptoms of schizophrenia

tends to increase the likelihood of violence by a spouse or partner

Pregnancy

a monolouge using intense, unterrupted words and ignoring anyone else's attempts to enter into the conversation

Pressured speech

Direct external benefits of being sick provide relief of anxiety, conflict, distress

Primary gains

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? Post a written schedule of daily activities, Use an overhead loudspeaker to announce events. Provide a consistent daily routine. Allow the client to choose free-time activities.

Provide a consistent daily routine.

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. 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.

SSRI antidepressants

Prozac, Zoloft, Sertraline. First line of tx for anxiety and OCD

Medications to treat BPD

Psychotropic agents; antidepressants; anxiolytics; or mood stabilizers

olfactory hallucinations

Putrid, foul, and rancid smells of a repulsive nature such as blood, urine or feces; occasionally the order can be pleasant (typically associated w/ stroke, tumor, seizures and dementias).

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner,Throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?

Reduce environmental stimuli

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following intervention should the nurse include in the plan?

Renew the prescription for the client every four hours (for a maximum of 24 hours)

Mic A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? Confront the staff member. Encourage the client to report the incident. Document the incident in the client's health record. Report the occurrence to the charge nurse.

Report the occurrence to the charge nurse.

Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness

Repression

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestation should the nurse expect?

Rhinorrhea

Suicide gestures

Self-directed actions that result in no injury but were done in such a way that others would interpret the act as suicidal behavior (e.g. minor scratches on the wrist w/ a plastic knife).

Anxiety d/o's

Separation anxiety d/o Specific phobias Agoraphobia Social Anxiety d/o Panic d/o generalized anxiety d/o (GAD)

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take? Set limits for the relationship Promote the use of transference by the client Instruct the client on how he should behave. Engage in friendly interactions with the client.

Set limits for the relationship

A nurse in a emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a Ballet performance. Which of the following statements by the parent acknowledges the clients diagnosis?

She won't let me take the trash from her room. I'm concerned about what she has in there.

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? Shuffling gait Hypotension Decreased WBC count Blurred vision

Shuffling gait

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of ethical principle of justice?

Spending adequate time with a client who is verbally abusive.

Demonstrating an inability to reconcile negative and positive attributes of self or others. Example: A client tells the nurse that she is the only one who cares about her, yet the following day the same client refuses to talk to the nurse.

Splitting

A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? St. John's wort Saw palmetto Echinacea Ginkgo

St. John's wort

A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorderAfter returning from military deployment. Which of the following is the priority action for the nurse to take?

Stay with a client when flashbacks occur.

Regression

Sudden use of childlike or primitive behaviors that do not correlate with the person's current developmental level

A nurse Is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

Suggest forming a weekly support group for parents who have experienced the death of a child.

5 levels of suicidal behaviour

Suicidal ideation, Suicidal Threats, Suicidal Gestures, Suicide attempts, Completed Suicide

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 child is leaving for college. The client is ambivalent about their upcoming retirement.

The client recently lost a grandparent in a motor vehicle crash.

Extrapyramidal Symptoms

The general term for a variety of motor responses, such as tremors, that can occur as side effects of antipsychotic medications

concrete thinking

Thinking grounded in immediate experience rather than abstraction. There is an overemphasis on specific detail as opposed to general and abstract concepts.

Chronic (sustained trait) Anxiety

This level of anxiety is one that usually develops over time, often starting in childhood. The adult how experiences this anxiety might display that anxiety in physical manifestations (fatigue or frequent HA's)

Acute anxiety (Immediate state)

This level of anxiety is precipitated by an imminent loss or change that threatens one's sense of security

Circumstantiality

Thought and speech associated w/ excessive and unnecessary detail that is usually relevant to a question and the answer is ultimately provided

A nurse is assessing a client who has bulimia nervosa . The nurse should expect which of the following findings?

Tooth erosion

Conversion d/o

Unexplained sensory or motor deficits associated w/ psychological factors, typically involves significant functional impairment, "la belle indifference"

A nurse in a providers office is interviewing an older adult client. Which of the following actions should the nurse plan to take?

Use a screening tool to evaluate the client for depression

AIMS (Abnormal Involuntary movement scale)

Used to screen for presence of EPS

Anxious mood or anxiety

Vague diffuse apprehension that is associated w/ feelings of uncertainty and helplessness in response to the emotional appraisal of a threatening stimulus

SNRI antidepressant

Venlafaxine; duloxetine -effective in the treatment of anxiety d/o

Anxiety

Viewed on a continuum w/ increasing levels of anxiety leading to decreasing ability to function

Suppression

Voluntarily denying unpleasant thoughts and feelings

ECT (Electroconvulsive Therapy)

a biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient

Boundaries

a conscious set of behaviors associated w/ not following recommended health care activities, such as not taking physician-ordered meds. (Reasons for noncompliance vary but could be related to: not being able to afford medications, being asymptomatic, not understanding the need for the tx, minimizing the seriousness of the problem, or a way of reasserting control).

Grandeur (Grandiose delusion)

a false sense of possessing wealth, fame, or power

completed suicide

a suicide attempt that results in death

bizarre behavior

activity that the person's culture would regard as totally odd, unusual, or strange

EPS (Extrapyramidal Symptoms)

acute dystonia - severe spasm of the tongue, neck, face and back, crisis situation that requires rapid treatment nursing actions - begin to monitor for acute dystonia anywhere between 1-5 days after admin of first dose, treat with an antiparkinsonian agents such as benztropine, IM or IV admin diphenhydramine, stay with client and monitor airway until spasms subside

Compulsion

am unremitting, repetitive urge to perform a behavior (hand washing) or mental act (praying) in response to an obsession in order to prevent or reduce stress and not to provide pleasure or gratification

OCD (Obsessive Compulsive Disorder)

an anxiety disorder characterized by unwanted repetitive thoughts and/or actions

GAD (Generalized Anxiety Disorder)

an anxiety disorder in which a person is continually tense, apprehensive, and in a state of autonomic nervous system arousal, sx for a min of 6 weeks

Depressed Mood

an individual;s sustained emotional tone which significantly influences behavior, personality, and perception

Mood

an individuals sustained emotional tone which significantly influences behavior, personality, and perception

phobia

an irrational fear

Acute stress disorder following sexual assault

appear and persist at least 3 days to 1 month, manifestations lasting longer than 1 month are classified as PTSD

Delusion of thought broadcasting

belief that others can hear one's thoughts

Somatic delusion

belief that something highly unusual is happening to one's body or internal organs

Other medications used to treat anxiety disorder

beta blockers and antihistamines decrease anxiety, anti convulsants are used as mood stabilizers for a client experiencing anxiety

Panic level of anxiety

characterized by markedly disturbed behavior; client is not able to process what is occurring in the environment and may lose touch with reality; extreme fright and horror; dysfunction in speech, inability to sleep, delusions, and hallucinations

Rationalization

creating reasonable and acceptable explanations for unacceptable behavior

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Discuss new relaxation techniques B. Show the client how to change the behaviour C. Distract the client w/ a tv show D. Stay w/ the client and remain quiet

d

tactile

experiencing pain or discomfort w/ no apparent stimuli; feeling electrical sensations coming from the ground, inanimate objects or other people

Pschyomotor retardation

extreme slowdown of physical movements when posture slumps; speech is slowed; and digestion becomes sluggish

Agoraphobia

fear or avoidance of situations, such as crowds or wide open places, where one has felt loss of control and panic

Delusion

fixed, false belief that cannot be changed by logical reasoning or evidence

antianxiety medications

helpful in treating manifestations of anxiety d/o. Bensodiazepines (diazepam) are indicated for short-term use. Buspirone is effective in managing anxiety and can be taken for long-term therapy of anxiety

Rape-trauma syndrome

initial emotional reaction: expressed reaction is overt and consists of emotional outbursts, including laughing, crying, hysteria, anger, and incoherence; controlled reaction is ambiguous, appearing calm and have blunted affect, but can be confused, have difficulty making decisions and feel numb Following initial emotional reaction, clients experience a variety of emotional reactions, including embarrassment, desire for revenge, guilt, anger, fear, anxiety, and denial. Somatic reaction can occur alter in which the client can have a variety of physical manifestations, including muscle tension, headaches, sleep disturbances, GI distress, genitourinary such as vaginal pain or discomfort

Loose associations

lack of logical relationship between thoughts and ideas that renders speech and thought inexact, vague, and unfocused

Early indications of lithium toxicity

lithium level 1.5-2.0 mEq/L manifestations: mental confusion, sedation, poor coordination, coarse tremors, and ongoing GI distress, including N/V/D Nursing actions: instruct client to withhold medication and notify provider, admin new dosage based on blood lithium and sodium levels, excretion can need to be promoted

Severe lithium toxicity

lithium level greater than 2.5 mEq/L manifestations: rapid progression of manifestations leading to coma and death Nursing actions: hemodialysis can be warranted

Low self

major problem in pt population

Stages of Alzheimer's

mild, moderate, severe

Perseveration

persistent repetition of the same word or idea in response to different questions

Vulnerable persons

persons at greatest risk for violence when they try to leave an abusive relationship

Denial

pretending the truth is not reality to manage the anxiety of acknowledging what is real

Tangentiality

similar to curcumstantiality but the person never returns to the central point and never answers the question

clang associations

speech directed by the sounds of words, as in combining words that rhyme rather than using appropriate ones

Word salad (incoherence)

speech or thinking that is essentially incomprehensible to others because of the mixture of words and phrases are meaningless to the listener and the speaker as well; the highest level of thought disorganization

Malingering or factitious d/o

willful control of sx

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (SATA) A. Hypotension B. Paralytic ileus C. Memory loss D. Poluyuria E. Confusion

C E

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states," i'm so fat I can't even stand to look at myself."Which of the following therapeutic response demonstrates the nurses use of summarizing?

" you're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."

A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective? "I journal when I find it difficult to talk." "I pray when I begin to breathe fast." "I fix myself a pot of coffee when I get anxious." "I exercise when my neck is tense."

"I fix myself a pot of coffee when I get anxious."

A nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. Which of the following statements by the clients indicate adaptive coping? (Select all that apply) "I exercise aerobically three times a day for 30 minutes at a time. " I get 7 hours of sleep at night by skipping afternoon naps." "I think about being on my favorite beach vacation when I get anxious." "I tense and release my muscles, starting with my feet." "I see the glass as half-full when it starts looking empty."

"I get 7 hours of sleep at night by skipping afternoon naps." "I think about being on my favorite beach vacation when I get anxious." "I tense and release my muscles, starting with my feet." "I see the glass as half-full when it starts looking empty."

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."

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? "Information regarding clients should remain confidential until after their death." "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." "As long as client identity is disguised, their health information can be shared between professionals on the internet." "In the event a client threatens harm to others, medications can be administered without consent."

"In the event a client threatens harm to others, medications can be administered without consent."

A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make? "Do you think your anxiety is worse than everyone else's?" "Tell me what has been happening lately." "It doesn't appear as though you are feeling anxious." "I think you should see a therapist."

"Tell me what has been happening lately."

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first? "What are the voices telling you?" "How often do you hear the voices?" "I know you hear the voices, but I do not." "The voices are part of your illness."

"What are the voices telling you?"

A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statement should the nurse make? "I understand your grief. I lost a baby also." "You may hold your baby as long as you want." "I have called for the chaplain to come and stay with you." "This is for the best. Your baby was very ill."

"You may hold your baby as long

GAD

- client exhibits uncontrollable, excessive worry for the majority of days over at least 6 mos - causes significant impairment in 1 or more areas of functioning (work-related duties) - manifestations include: muscle tension, restlessness, avoidance of stressful activities or events, increased time and effort required to prepare for stressful activities or events, procrastination in decision making, sleep disturbance

Vulnerable person characteristics

-Low self esteem -feelings of helplessness, hopelessness, powerlessness, guilt/shame -attempts to protect the perpetrator -accepts responsibility for the abuse -possible denial of the severity of the situation -potential feelings of anger and terror

A home health nurse is reinforcing coping strategies with the family caregiver of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? (Select all that apply.) Actions to reduce stress Identification of a social support system Referral to available community resources Instruction on client medication administration Expected physiological changes of the disease

Actions to reduce stress Identification of a social support system Referral to available community resources Expected physiological changes of the disease

A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which the following conditions should the nurse include in the discussion? (Select all that apply.) Anxiety Obsessive-compulsive disorder Schizophrenia Breathing-related sleep disorder Depression

Anxiety Obsessive-compulsive disorder Depression

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching?

Apply restraints when other means of managing the clients behavior have failed.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling what to do." Which of the following actions should the nurse take? Tell the client that the voices do not really exist. Touch the client to help reduce feelings of anxiety. Instruct the client to go to a quiet room when the voices start talking. Ask the client what the voices are saying.

Ask the client what the voices are saying.

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, a 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 they have questions ooncerns 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 they have 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 they have any thoughts or questions about the treatment plan.

What psychiatric conditions do adults usually have w/ ADHD

Bipolar d/o OCD Social phoibias Alcohol dependence

Contraindications for ECT

Cardiovascular d/o and Cerebrovascular d/o

A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? Obtain the weight of a client who has bipolar disorder and is experiencing mania. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted

Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

Spectrum d/o

Classic Autism Rett's D/o Childhood disintegrative d/o Asperger's d/o

Altruism

Dealing with anxiety by reaching out to others

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.) Diazepam 5 mg IV bolus Clonidine 0.1 mg transdermal patch Naltrexone 380 mg IM Bupropion 150 mg PO

Diazepam 5 mg IV boulders

Alcohol withdrawal medications

Diazepam, Carbamazepine, Clonidine, Chlordiazepoxide, phenobarbital, naltrexone

Shifting feelings r/t an object, person, or situation to another less threatening object, person, or situation

Displacement

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take? Monitor the client closely to prevent self-mutilation. Set limits to prevent exploitation of other clients. Discourage flamboyant or seductive behaviors. Give positive feedback when client is assertive with staff or clients.

Give positive feedback when client is assertive with staff or clients.

Is ised to describe a social system composed of two or more persons who co-exist within the context of some expectations of reciprocal affection and/or mutual responsibility. Members do not have to live together, or be related, in order to be considered family.

Group

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

I will update the plan of care as a clients manifestations of depression change.

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make?

I'll stay with you just in case you want to talk.

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

Ideas of reference

A nurse is caring for a client who is in An abusive relationshipAnd is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?

Identify signs of escalation of violence.

A emotion that is incongruent with the situation

Inappropriate affect

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the findings should the nurse identify as a possible indicator of neglect? Increased confusion Sleep disturbances Cluttered environment Inappropriate dress

Inappropriate dress

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)

Following sexual assault patient-centered care

Lab tests: obtain blood for HIV, Hepatitis B and C, collect samples for legal evidence (hair, skin, semen) Treatment of any injuries and documenting care given administer prophylactic treatment for STI's (syphilis, chlamydia, gonorrhea, HIV, and hepatitis exposure) Evaluate pregnancy risk and provide prevention (emergency contraception) Assess for suicide risk Provide nonjudgmental, empathetic care Obtain informed consent to collect data that can used as legal evidence (photos, pelvic exam)

A school nurse is assessing a school age child to experience the traumatic loss of a parent eight months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing posttraumatic stress disorder?

Lack of interest in the upcoming holiday

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. Avoid displaying an emotional response. Offer sympathetic support. Verbalize disapproval of the client's substance abuse.

Maintain a nonjudgmental attitude.

Nursing care for MDD

Mileu therapy; suicide risk assessments, self-care monitoring, therapeutic communication, maintenance of safe environment, counseling Medication teaching; Do not discontinue meds suddenly, Therapeutic effects are not immediate, can take several weeks or more to reach full effect' notify provider of any thoughts of suicide' avoid alcohol while taking an antidepressant Citalopram- SSRI; Fluoxetine- SSRI; Sertraline- SSRI; Amitriptyline- tricyclic antidepressant; Phenelzine- MAOI (avoid foods w/ tramine, such as ripe avocados, figs, fermented or smoked meats, liver, dried or cured fish, most cheeses, some beer and wine, protein dietary supplements); Bupropion- atypical antidepressant; Venlafaxine- SNRI; Duloxetine- SNRI

Monitoring Blood Levels for Lithium Therapy

Monitor plasma lithium levels while undergoing treatment; initiation of treatment, monitor levels every 2-3 days until stable and then every 1-3 months. Closely monitor levels after any dosage change. Lithium blood levels should be obtained in the morning, 10-12 hrs after last dose. Maintenance level range: 0.6-1.2 mEq/L initial treatment of manic episode, higher levels can be required: 1-1.5 mEq/L

Labile mood

Oscillations in mood i.g. euphoria and depression or anxiety

Alzheimer's diagnostic testing

PET scan to identify plaques in the brain; no cure; meds to slow progress-cholinesterase inhibitors; symptomatic tx- antidepressants, mood stabilizers, antipsychotics

Undoing

Performing an act to make up for prior behavior

A nurse is caring for an older adult client who is experiencing delirium. Which of the following intervention should the nurse include in the clients plan of care?

Permit the client to perform daily rituals to decrease anxiety.

Types of violence

Physical- occurs when physical pain or harm is involved Sexual- occurs when sexual contact takes place w/o consent Emotional- includes behavior that minimizes an individuals feelings of self-worth or humiliates, threatens, or intimidates a family member Neglect- includes failure to provide physical care, ie, feeding, emotional care, education, necessary health / dental care Economic- failure to provide for the needs of a vulnerable person when adequate funds are available, unpaid bills resulting in disconnection of utilities

A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? Respite care Partial hospitalization Adult day care program Geropsychiatric unit

Respite care

Conversion

Responding to stress through the unconscious development of physical manifestations not caused by a physical illness

A nurse in a mental health clinic is planning care for four clients. Which of the following Should the nurse delegate to an assistive personnel?

Stay with a client who has anorexia nervosa for one hour after meal times

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

Insight

The ability to perceive oneself realistically and understand oneself; awareness of limitations, consequences of actions, and awareness of one's illness; the ability to understand the true nature of one's situation and accept some personal responsibility for that situation

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? The client needs excessive external input to make everyday decisions. The client demonstrates a dedication to their job that excludes time for leisure activities. The client adheres to a rigid set of rules. The client has difficulty starting new relationships unless they feel accepted.

The client needs excessive external input to make everyday decisions.

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? The client's chart indicates a 1.36-kg (3-lb) weight gain 1 month. The client reports an inability to breathe easily. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL. The client reports having recently started smoking cigarettes.

The client reports an inability to breathe easily.

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine?

WBC count, 2,500/mm3

Homicidal ideation

thoughts of killing another person

Physical signs of child abuse

unusual bruising (abd, back, buttocks), be suspicious of bruises or telts that resemble shape of belt buckle, burns covering clove or stocking area can indicate forced immersion in boiling water, small round burns can be from lit cigarettes, Fx w/ unusual features (spiral fx of forearm), Human bite marks, head injuries, altered LOC, unequal or nonreactive pupils, NV, bruising on infant before age 6 mos, intracranial hemorrhage, resp distress, bulging fontanels, retinal hemorrhage

Stimuli seen in the form of flashes of light, geometric figures, cartoon figures, and/or elaborate and complex scenes or visions; visions can be pleasant or terrifying

visual

A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statements by the client indicates he is ready for discharge? "Right now, I can't bathe or dress myself, but that's not important." "When I get home, I'm going to let the people who put me here know how I angry I am." "I will take my medicines as I should and know to call the number you gave me if I have bad thoughts." "Taking care of myself is important, but it's okay if I want to take a break and not do anything."

"I will take my medicines as I should and know to call the number you gave me if I have bad thoughts."

Moderate anxiety

-occurs when mild anxiety escalates. -slightly reduced perception and processing of information occurs, and selective inattention can occur. -ability to think clearly is hampered, but learning and problem-solving can still occur. -other characteristics include concentration difficulties, tiredness, pacing, change in voice pitch, voice tremors, shakiness, and increased heart rate and respiratory rate. -the client can report somatic manifestations including headaches, backache, urinary urgency and frequency, and insomnia. -the client who has this type of anxiety usually benefits from the direction of others

A nurse working on an acute mental health unit is admitting a client who has major depressive d/o and comorbid anxiety d/o. Which of the following actions is the nurse's priority? A. Placing the client on one-to-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Teaching the client about meds adverse effects

A

A nurse is teaching a group of guardians about manifestations of conduct disorder. Which of the following findings should the nurse include? (SATA) A. Bullying of others B. Threats of suicide C. Law-breaking activities D. Narcissistic behavior E. Flat affect

A B C

A nurse is caring for a client who has schizophrenia and was prescribed a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? A. Shuffling gait B. Hypotension C. Decreased WBC count D. Blurred vision

A. Shuffling gait Benztropine is used to treat parkinsonism manifestations, such as shuffling gait.

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine. A. WBC 2500/mm3 B. Hbg 11.5 mg/dL C. Platelets 150,000/mm3 D. RBC 3.5 million/mm3

A. WBC 2500/mm3 Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count below 3000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.

A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? Arrange one-to-one observation of the client. Encourage interaction with the client's peers. Administer medication for depressive disorder. Encourage the client to attend a support group.

Arrange one-to-one observation of the client.

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the groups time. Which of the following intervention should the nurse implement?

Ask group members to discuss their feelings about the clients monopolizing behavior

A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching? Ensure a family member can be present during treatment. Increase fluid intake for 24 hr before the treatment starts. Change position slowly when the treatment is complete. Avoid looking directly at the light during treatment.

Avoid looking directly at the light during treatment.

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway w/ another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager B. Tell the nurse to stop discussing the behavior C. Provide an in-service program about confidentiality D. Complete an incident report

B

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first? A. Encourage the client to participate in group therapy on the unit. B. Initiate one-to-one observation of the client C. Focus the client on reality D. Notify the provider of the client's statements

B

A nurse is caring for a client who has bipolar d/o. The client states, " I am very rich, and I feel I mist give my money to you." Which of the following responses should the nurse make? A. "Why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you." C. 'I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money is inappropriate."

B

A nurse is caring for a client who is speaking in a loud voice w/ clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling B. Request that other staff members remain close by C. Move as close to the client as possible D. Walk away from the client

B

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have a cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? a. Reaction Formation B. Denial C. Displacement D. Sublimination

B

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority? A. Client's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Clint's insight into the reasons for the decision

B

A nurse is caring for a client who is in mechanical restraints/ Which of the following stmts should the nurse include in the documentation? (SATA) A. "Client ate most of their breakfast." B. "Client was offered 8 oz of water every hr. " C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." E. "Client acted out after lunch."

B C D

-A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? (SATA) A. Sunken fontanels B. Resp distress C. Retinal hemorrhage D. Altered LOC E. Increase in head circumference

B C D E

A Charge nurse is reviewing Kubler-Ross: Five stages of grief w/ a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (SATA) A. Disequilibrium B. Denial C. Barganing D. Anger E. Depression

B C D E

A nurse is assessing a client who has alcohol use d/o and is experiencing withdrawal. Which of the following findings should the nurse expect? (SATA) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

B D E

A nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. Which of the following statements by the clients indicates adaptive coping? (Select all that apply) A. "I exercise aerobically three times a day for 30 minutes at a time." B. "I get 7 hours of sleep at night by skipping afternoon naps." C. "I think about being on my favorite beach vacation when I get anxious." D. "I tense and release my muscles, starting with my feet." E. "I see the glass as half-full when it starts looking empty."

B. "I get 7 hours of sleep at night by skipping afternoon naps." C. "I think about being on my favorite beach vacation when I get anxious." D. "I tense and release my muscles, starting with my feet." E. "I see the glass as half-full when it starts looking empt

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? A. "You probably want to hold your baby." B. "I'll stay with you in case you want to talk." C. "I know how you must be feeling." D. "It hurts now, but things will be better soon."

B. "I'll stay with you in case you want to talk." This response indicates the nurse's interest in the client and a desire to understand the client's feelings.

The nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? A. "I'm relieved now that my financial affairs are in order." B. "It is easier to talk about my feelings now." C. "Suddenly I have enough energy to do anything I want." D. "Thank you for always taking such good care of me."

B. "It is easier to talk about my feelings now." When clients express their feelings, this indicates a positive treatment outcome.

A nurse is developing a plan of care for a client who has conversion d/o. Which of the following actions should the nurse include? A. Encourage the client to spend time alone in their room B. Monitor the client for self-harm once per day C. Allow the client unlimited time to discuss physical manifestations D. Discuss alternative coping strategies w/ the client

D

A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take? A. Speak to the provider about adding an MAOI to the current medication regimen. B. Explain that antidepressants often take several weeks to be fully effective. C. Tell the client that the provider will need to change citalopram to a different medication. D. Recommend a sleep study be done on the client.

B. Explain that antidepressants often take several weeks to be fully effective.

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? A. Advise the client to take frequent sips of water. B. Instruct the client to avoid driving during initial therapy. C. Consult a dietitian for a calorie-controlled diet plan. D. Recommend that the client exercise regularly.

B. Instruct the client to avoid driving during initial therapy. The greatest risk to this client is injury resulting from dizziness or drowsiness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy.

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply) A. Urinary retention and constipation B. Tongue thrusting and lip smacking C. Fine hand tremors and pill rolling D. Facial grimacing and eye blinking E. Involuntary pelvic rocking and hip thrusting movements

B. Tongue thrusting and lip smacking D. Facial grimacing and eye blinking E. Involuntary pelvic rocking and hip thrusting movements

A nurse is planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse visit first? A. A client who received a burn on the arm using a hot iron at home. B. A client who requests a change of antipsychotic medication due to some new adverse effects C. A client who reports hearing a voice saying that life is not worth living anymore. D. A client who tells the nurse aboutr experiencing manifestations of severe anxiety before and during a job interview.

C

A nurse manager is discussing the care of a client who has a personality d/o w/ a newly licensed nurse. Whick of the following stmts by the nurse indicates an understanding of teaching? A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality d/o to increase socialization." C. "I should practice limit setting to help prevent client manipulation." D. "I should implement assertiveness training w/ clients who have antisocial personality d/o. "

C

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Narcissistic behaviour B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C

A nurse on an acute mental health unit forms a group of focus on self-management of medications. At each of the meetings, two of the members conspire together to exclude the rest of the group. This is an example of which of the following concepts? A. Triangulation B. Group process C. Subgroup D. Hidden agenda

C

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching?

I will talk about my feelings with a close friend

A nurse is caring for a client following the loss of a partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience. Select all steps in order of occurrence A. Developing awareness B. Restitution C. Shock and disbelief D. Recovery E. Resolution of the loss

C A B E D

A charge nurse is discussing the characteristics of a nurse-client relationship w/ a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (SATA) A. The need of both participants are met B. An emotional commitment exists between participants C. It is goal-directed D. Behavioral change is encouraged E. A termination date is established

C D E

A nurse is assisting w/ a court-ordered eval of a client who has antisocial personality d/o. Which of the following findings should the nurse expect? A. Demonstrates extreme anxiety when placed in social situation B. Often engages in magical thinking C. Attempts to convince other clients to relinquish their belongings D. Becomes agitated if personal area is not neat and orderly E. Blames others for personal past and current problems

C E

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

A nurse is providing teaching to the partner of a client who is in a rehabilitation programFor alcohol use disorder. The nurse should identify that which of the following statements by the client partner indicates an understanding of the teaching?

I will not take charge of my partners work responsibilities.

A nurse is teaching a client who has a new prescription for alprazolam to treat insomnia. Which of the following instructions should the nurse included? A. "Take this medication every night before sleep." B. "Take this mediation with a high fat meal." C. "Avoid activities that require alertness such as driving." D. "Monitor for urinary retention."

C. "Avoid activities that require alertness such as driving."

nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective? A. "I journal when I find it difficult to talk." B. "I pray when I begin to breathe fast." C. "I fix myself a pot of coffee when I get anxious." D. "I exercise when my neck is tense."

C. "I fix myself a pot of coffee when I get anxious."

A nurse is caring for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things." The nurse correctly identifies this finding as which of the following? Command hallucination Gustatory hallucination Cognitive distortion Somatic delusion

Command hallucination

a behavior reaction to memory loss in which the person fills in memory gaps w/ inappropriate words or a detailed fantasy, the purpose of which is to maintain selt-esteem

Confabulation

A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their childd's condition, which of the following responses should the nurse mane? A "I think your child is getting better, what have you noticed?" B. "I'm sure everything will be ok, It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand that you're concerned. Let's discuss what concerns you have specifically."

D

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (SATA) A. Genitourinary soreness B. Difficulties w/ low self-esteem C. Sleep disturbances D. Emotional outbursts E. Difficulty making decisions

D E

A nurse is caring for a client who has attempted suicide and has alcohol use disorder. Which of the following statements indicates that the client is using a positive coping mechanism? A. "I will limit my drinking to the weekends." B. "I will stay in my room and avoid others when I'm feeling down." C. "I will be dependent on others for the time being." D. "I will attend daily group therapy sessions to practice relaxation techniques."

D. "I will attend daily group therapy sessions to practice relaxation techniques." Relaxation techniques decrease the risk for self-harm by decreasing stress, anxiety, and depression

A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following statements by the client indicates an understanding of the teaching? A. "I should expect to feel better after 24 hours of starting this medication." B. "I should not take this medicine with grapefruit juice." C. "I'll take this medicine with food." D. "I'll take this medicine first thing in the morning."

D. "I'll take this medicine first thing in the morning."

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching? A. "You will need to consume a low-salt diet while on this medication." B. "You will need your blood levels drawn weekly during the first month." C. "You will need to take this medication on an empty stomach." D. "You will need to stop this medication if you experience diarrhea."

D. "You will need to stop this medication if you experience diarrhea."

A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching? A. Have a family member present during treatment. B. Increase fluid intake. C. Change position slowly. D. Wear sunglasses when outdoors.

D. Wear sunglasses when outdoors. Light therapy, or phototherapy can cause eye strain and sensitivity to light.

A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? Reduced appetite Fatigue Dark urine Sweating

Dark urine

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first? Ask the client for permission to take photographs. Document the client's verbatim statements. Provide community sexual assault support contacts. Determine any physical signs of injury.

Document the client's verbatim statements.

Dementia

Does not clear up; lifelong dx; sx do not resolve; gradual onset; multiple cognitive deficits; primarily memory loss

Silent Rape Reaction

Does not report or tell anyone of sexual assault Abrupt changes in relationships with partners Nightmares Increased anxiety during interview Marked changes in sexual behavior Sudden onset of phonic reactions No verbalization of the occurrence of the sexual assault

PTSD Prevention

During the incident, be aware of need for breaks, rest adequate water and nutrition. provide emotional support for those involved in the incident encourage staff to support each other debrief with others following the incident encourage expression of feelings by all involved use offered counseling resources

Manifestations include abdominal cramping, vomiting, tremors, restlessness and inability to sleep; increased heart rate, transient hallucinations or illusions, anxiety, increased BP, respiratory rate, and temperature, tonic-clonic seizures

ETOH Withdrawal Symptoms

is used to describe a social system composed of two or more persons who co-exist w/i the context of some expectations of reciprocal affection and/or mutual responsibility. Members do not have to live together, or be related, in order to be considered family. (Please think about this definition, especially if it differs from one you may currently have. Each individual's "family" is who he/she says it is)

Family

Feelings of hopelessness or despair

Feelings of discouragement about the future. Common with major depressive disorder and dysthymia.

A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.) Feelings of hopelessness Pressured speech Grandiosity Anhedonia Flat facial expression

Feelings of hopelessness Anhedonia Flat facial expression

Why should one be careful when reporting elder abuse?

If elder abuse is reported, the state can take all belongings and financials that belonged to the pt. Always be 100% certain when reporting elder abuse. Be sure pt is competent and aware- some elders know it is happening and allow it to go on. Discuss w/ elder about the abuse going on, also discuss respite care w/ caregivers. Caregiver needs should come first; goal is to keep elder at home, not in SNF, Recognize their strengths, not just their problems

A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority? Vitamin deficiency Diaphoresis Tremors Illusions

Illusions

A nurse is teaching the partner of a client who has bipolar disorder how do identify manifestations of acute mania. Which of the following findings should the clients partner report to the provider?

Inability to sleep

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? Allow manipulation so as to not raise the client's anxiety. Avoid discussing past behaviors with the client. Institute consequences for manipulative behavior. Bargain with the client to discourage manipulative behavior.

Institute consequences for manipulative behavior.

the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly

Judgment

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? Tardive dyskinesia Neuroleptic malignant syndrome Acute dystonia Pseudoparkinsonism

Neuroleptic malignant syndrome

A nurse is planning care for a client who has made repeated physical threats towards others on the unit. Although the client does not want to leave the unit, the nurse request 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

A nurse is caring for a client who has a serum lithium level of 2.0 mEq/L. Which of the following is the priority action for the nurse to take? Notify the primary provider the result indicates toxicity. Continue to monitor this expected maintenance level. Request the provider increase the client's medication dose. Check the client for manifestations of hypernatremia.

Notify the primary provider the result indicates toxicity.

Client attempts to suppress persistent thoughts or urges that cause anxiety through compulsive or obsessive behaviours (repetitive handwashing). Obsessions and compulsions are time-consuming resulting in impaired social and occupational functioning

OCD

a false sense that oters are against them; excessive or extreme and irrational suspiciousness and mistrustfulness of others actions or perceived intentions (ex.- the belief that others that are spying on him/her; that the FBI is "out to get me"; or a loved one is trying to poison him/her)

Persecutory or Paranoid

Anorexia nervosa

Persistent energy intake restriction leading to significantly low body weight in context of age, sex, developmental path, and physical health Fear of gaining weight or becoming fat Disturbance in self-perceived weight or shape

A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent? Telling his parents that he doesn't want to talk about the suicide attempt. Stating that he wants to be with his peers more than with his parents. Preferring to eat his meals while watching TV. Planning to give his CD collection to his girlfriend.

Planning to give his CD collection to his girlfriend.

Post-Crisis Phase

Remove restraint or seclusion ; calmly discuss behavior & coping mechanisms; do not take pt anger personally; use assertive communication skills, conflict resolution; be calm & nonjudgmental

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? Decrease distractions during meal times. Provide positive feedback when the child completes a task. Clearly identify consequences for unacceptable behavior. Remove unnecessary equipment from the child's surroundings.

Remove unnecessary equipment from the child's surroundings.

Anorexia Nervosa - 2 Types

Restricting type : individual drastically restricts food intake and does not binge or purge Binge-eating/purging type : individual engages in binge-eating or purging behaviors

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors? The client has borderline personality disorder. The client has a parent who has dependent personality disorder. The client has a history of bulimia nervosa. The client recently received a promotion at work.

The client has borderline personality disorder.

Schizophrenia

The client has psychotic thinking or behavior present for at least 6 mos. Areas of functions including school or work, self care, and interpersonal realties are significantly impaired

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.

Delirium

an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech, sudden onset, does clear up w/ tx

Types of Hallucinations

auditory, visual, olfactory, gustatory, tactile

Identification

conscious or unconscious assumption of the characteristics of another individual or group

Guarded (or Suspicious)

displays of behaviour r/t being cautious, reserved, or suspiciousness such as looking over one's shoulder, closely watching what one says, and scanning the environment w/ one's eyes

abuse and violence happens w/ which kind of people

domestic violence happens in ALL people regardless of race, culture, financial status, etc. Battered immigrant women at particular risk- too afraid to report due to risk of being deported

Crisis phase

inform pt that behavior is out of control & staff is taking control to provide safety & prevent injury Use of restraint or seclusion only if necessary

Can pt w/ somatic illness d/o control their sx?

no . Sx or magnified health concerns are not under pt conscious control. they are not doing it on purpose. "this is real"

Thought Blocking

stopping abruptly in the middle of a sentence or train of thought; sometimes client is unable to continue the idea

the belief that societal systems, laws, and regulations exist purely to restrain, control and inhibit its members

of control or influence

Considered a medical emergency. can occur 2-3 days after cessation of alcohol. manifestations include severe disorientation, psychotic manifestations (hallucinations), severe HTN, cardiac dysrhythmias, and delirium. Can progress to death.

Alcohol withdrawal delirium

Compensation

emphasizing personal strengths in one area to shift focus from failure in another area

Types of anxiety

normal, acute (immediate state, chronic (sustained state)

MDD can also present as

psychotic features and postpartum onset

following morning. The client A nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility the asks the nurse why he has to go to "that place." Which of the following responses should the nurse make? "Your doctor feels that this is the best place for you right now." "Why don't you ask your doctor about that when she comes in to see you?" "Did your doctor or anyone else talk to you about going to the nursing home?" "Your family can't take care of you at home, so you will need to go there."

"Did your doctor or anyone else talk to you about going to the nursing home?"

A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide? "His favorite teacher committed suicide a few weeks ago." "He has slept 9 hours each night for the past 2 years." "He is very religious and attends services twice a week." "He spends much of his time with his two school friends."

"His favorite teacher committed suicide a few weeks ago."

Tx and interventions for child abuse

-child safety, wellbeing of the child being a priority -psychiatric eval/ poss long- term therapy/ play therapy (for very young child) - family therapy if reuniting feasible - psychiatric or substance abuse tx for parents -foster care (short or long term)

ASD (acute stress disorder)

severe reaction immediately following a traumatic event, often including amnesia about the event, emotional numbing, anxiety, detachment, and derealization; occurs 3 days-1 mo after event

Therapeutic Uses for Haldol

Treatment of acute and chronic psychotic disorders Schizophrenia spectrum disorders Bipolar disorder; primarily the manic phase Tourette disorder Agitation Prevention of N/V through blocking dopamine in the chemoreceptor trigger zone of the medulla

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 in a clinic is assessing a client whose partner that the client is at risk for complicated grief? died 4 months ago. Which of the following statements "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."

A nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make? "Oh, I'm so pleased that you finally put on clean clothes." "Why did your wear clean clothes and comb your hair today?" "Your mood must be lifting because you have on clean clothes and have combed your hair." "I see that you have on clean clothes and have combed your hair."

"I see that you have on clean clothes and have combed your hair."

A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? "I should eat a regular diet with normal amounts of salt and fluids." "I should discontinue the lithium when I begin to feel better." "I need to be careful to avoid becoming addicted to the lithium." "I can skip a dose of medication if my stomach is upset."

"I should eat a regular diet with normal amounts of salt and fluids."

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 perform screenings to identify clients at risk for suicide." "I should recognize the lethality of the suicide plan." "I should provide counseling for the family following the suicide of a client." "I should provide a safe environment to prevent the client from committing suicide."

"I should provide counseling for the family following the suicide of a client."

Suicidal threat

statement of intent accompanied by behavior changes that indicate a person has defined their plan to end their life

A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication? "You were made aware of the consequences of negative behavior." "I understand that you are angry. However, I followed the appropriate protocol." "You need to calm down before discussing this matter any further." "Why did you make the choice to behave negatively?"

"I understand that you are angry. However, I followed the appropriate protocol."

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? "I'm relieved now that my financial affairs are in order." "It is easier to talk about my feelings now." "Suddenly I have enough energy to do anything I want." "Thank you for always taking such good care of me."

"It is easier to talk about my feelings now."

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate? "This is where you live now." "This is a safer place for you to live." "Tell me what you like to cook for dinner." "Your family said there is no one to care for you at home."

"Tell me what you like to cook for dinner."

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 might notice an increase in saliva while taking this medication." "You might 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 might experience difficulties with sexual functioning while taking this medication."

Mild Anxiety

-Occurs in the normal experience of every day living - Increases one's ability to perceive reality -Identifiable cause of anxiety - Vague feeling of mild discomfort, restlessness, irritability, impatience and apprehension - Mild tension-relieving behaviours (finder or foot tapping, fidgeting, lip chewing)

Escalation phase

-Set boundries -Take control, provide directions in calm, firm voice - Direct pt to room or quiet area -offer med again -If ineffective, get other staff (show of force) -Aggression is unacceptable -RN/Staff will help maintain and regain control

Expected findings of MDD

-anergia (lack of energy) -anhedonia (lack of pleasure in the normal activities) -anxiety -reports of sluggishness (most common) or feeling unable to relax and sit still -vegetative findings, which include a change in eating patterns (usually anorexia in MDD), -sleep disturbances, change in bowel habits, decreased interest in sexual activity -somatic reports (fatigue, GI changes, pain)

Nursing interventions for hypochondriasis

-build rapportr and trust w. the client -Encourage independence in self-care -Administer medications as prescribed; antidepressants, anxiolytics -Client education: Participate in individual and group therapy, attend comminity support groups, utilize prescribed meds -Collaborate w/ provider to receive brief, frequent office visits -verbalise any feelings -utilize alternative coping mechanisms -perform stress managment techniques

Assessment for abuse of a pt

-forensic nurse had advanced training in collection of evidence for suspected or actual cases of sexual assult or other abuse - provider privacy when conducting interviews about family abuse -be direct, honest and professional -use language the client understands -be understanding and attnetive -use therapeutic techniques that demonstrate understanding -use open-ended questions to elicit descriptive responses -inform the client if a referral must be made to child or adult protective services and be sure to explain the process

Expected findings in Bipolar d/o

-labile mood w/ euphoria - agitation and irratibility -restlessness -dislike of interference and intolerance of criticism -increase in talking and activity -flight of ideas; rapid, continuous speech w/ sudden and frequent topic change -Grandiose view of self and abilities -Impulsivity:j spending money, giving away money or possessions -demanding and manipulative behaviour -distractibility and decreased attn span -poor judgement -attention-seeking behavior: flashy dress and makeup, inappropriate behavior -impairment of social and occupational functioning -decreased sleep -neglect of ADS's, including nutrition and hydration -possible presence of delusions and hallucinations -denial of illness Depressive characteristics: -Flat, blunted labile affect -tearfulness, crying -lack of energy -anhendonia: Loss of pleasure and lack of interest in hobbiess, activities, and sexual activity -Physical reports of discomfort/ pain -difficulty concentrating, focusing

Severe to Panic-Level anxiety interventions

-provide an environment that meets the physical and safety needs of the client. Remain w/ the client and remain calm. -provide a quiet environment w/ minimal stimulations -use meds and restraint, but only after less restrictive interventions have failedf to decrease anxiety to safer levels -encourage gross motor activities, such as walking and other forms of exercise -set limits by using firm, shourt, and simple statements. Repetition can be necessary. Speak slowly and in a low pitched voice. -direct the client to acknowledge reality and focus on what is present in the environment

Procedural care w/ ECT

-typical course is 2-3 x wk x a total of 6-12 tx for depression -providers obtain informed consent -pre-ECT workup includes CXR, BW, ECG. Benzo should be d/c as they will interfere w/ the seizure process -30 min prior, IM inj of atropine sulfate or glycopyrrolate is admin to decrease secritions that cause aspiration and to counteract any vagal stimulation effects (bradycardia) -at the time of procedure, anestesia provieder admins short-acting anesthetic (etomidate or propofol) via IV bolus -a muscle relaxant (succinylcholine) is then admin to paralyze the client's muscles during seizure activity, which decreases risk for injury. Succinylcholine paralyzes the resp muscles so the client req assistanct w/ breathing and oxygenation - severe HTN should be controlled b/c a short period of HTN occurs immediatly after ECT procedure -any cardiac conditions should be monitored and treated prior -the nurse assesss the client's and family's understanding knowledge of the procedure and provides teaching as necessary - an IV line is inserted and maintained until full recovery

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 Ib. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

14 mL 13.75 rounded up to 14

A nurse is caring for a client who lost a guardian to cancer last month. The client states, "I'd still have my guardian if the doctor would have made a dx sooner." Which of the following responses should the nurse mane? A. "You sound angry. Anger is a normal feeling associated w/ loss." B. "I think you would feel better if you talked about your feelings w/ a support group." C. "I understand just how you feel. I felt the same when my guardian died." D. "Do other members of your family also feel this way?"

A

A nurse is caring for an adolescent client who has anorexia nervosa w/ recent rapid wt loss and a current wt of 90 lbs. Which of the following stmts indicates the client is experiencing cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain wt." B. "Don't pretend like you don't know how fat I am." C. If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I seem myself as obese."

A

A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is highest priority? A. Advise the client aout the location of safe houses and shelters B. Encourage the client to participate in support group for survivors of abuse. C. Implement case managment to coordinate community and social services. D. Educate the client about the use of stress managemenmt techniques

A

A charge nurse is discussing mental status exams w/ a newly licensed nurse. Which of the following stmts by the newly licensed nurse indicates an understanding of teaching? (SATA) A. " To assess cognitive aility, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expressions." C. " To assess remote memory, I should have the client repeat a list of objects." D. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents."

A B C

A nurse is assessing a client who has illness anxiety d/o. Which of the following are expected for this d/o? (SATA) A. Obsessive thoughts about the disease B. History of childhood abuse C. Avoidance of health care providers D. Depressive d/o E. Narcissistic personality

A B C D

A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (SATA) A. Educational groups B. Medications dispensing programs C. Individual counseling programs D. Detoxification programs E. Family Therapy

A B C E

A nurse is assessing a client who has major depressive d/o. The nurse should identify which of the following client stmts as an overt comment about suicide? (SATA) A. "My family will be better off if I'm dead." B. "The stress in my life is too much to handle." C. "I wish my life was over." D. "I don't feel like I can ever be happy again." E. "If I kill myself then my problem will go away."

A C E

A nurse is assisting w/ the development of protocols to address the increasing # of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (SATA) A. Conducting a suicide risk screening on all new clients B. Creating a support group for family members of clients who completed suicide. C. Educating high school teens about suicide prevention. D. Initiating one-to-one observation for a client who has current suicidal ideations E. Teaching middle-school educators about warning indicators of suicide

A C E

recovery phase

talk about situation or trigger Help pt relax or sleep Explore alternatives to aggressive behavior Provide documentation of any injuries Debrief staff

A nurse is caring for a group of clients. Which of the following findings should the nurse report? A client who is taking clozapine and has a WBC count of 7,500/mm3 A client who is taking lamotrigine and has developed a rash A client who is taking valproate and has a platelet count of 150,000/mm3 A client who is taking lithium and has a lithium level of 1.2 mEg/L

A client who is taking lamotrigine and has developed a rash

Impulsive behavior (impulsivity)

tendency to act on urges, notions, or desires w/o adequate consideration of the consequences of the behavior

cycle of violence

tension building, acute battering, honeymoon, escalation and deescalation

Abstract Thinking

the ability to conceptualize ideas (e.g., finding meanings in proverbs) (Persons w. schizophrenia usually lack the ability for abstract thinking)

De-escalation

the act of decreasing overwhelming emotions r/t anxiety, fear, and/or frustration

Affect

the behavioral expression of emotion

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?

An older adult client who is bedbound and has a stage IV pressure ulcer.

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? Delusions Neologisms Anhedonia Echopraxia

Anhedonia

A client who has bipolar disorder is to be discharged home with a prescription for lithium. Which of the following statements indicates that client teaching regarding the medication has been effective? A. "I should eat a regular diet with normal amounts of salt and fluids." B. "I should discontinue the lithium when I begin to feel better." C. "I need to be careful to avoid becoming addicted to the lithium." D. "I can skip a dose of medication if my stomach is upset."

A. "I should eat a regular diet with normal amounts of salt and fluids." This statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity.

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, she does not respond. Which of the following actions should the nurse take before repeating the request to the client? A. Allow the client time to collect her thoughts. B. Prompt the client to give a response. C. Move on to the next client. D. Offer the client a suggestion for a goal.

A. Allow the client time to collect her thoughts. Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.

A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? A. Arrange one-to-one observation of the client. B. Encourage interaction with the client's peers. C. Administer medication for depressive disorder. D. Encourage the client to attend a support group.

A. Arrange one-to-one observation of the client. The greatest risk to the client is self-injury, Therefore, the priority nursing intervention is one-to-one observation to promote client safety.

A nurse manager is providing staff education about working clients who have a history of anger and aggression. Which of the following information should the nurse include on the teaching? (Select all that apply) A. Avoid wearing necklaces during client care. B. Know the layout of the facility. C. Stand directly in front of the client when talking. D. Bring security with you for all client interactions. E. Provide immediate verbal feedback for escalating behavior.

A. Avoid wearing necklaces during client care. B. Know the layout of the facility. E. Provide immediate verbal feedback for escalating behavior.

nurse is caring for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things." The nurse correctly identifies this finding as which of the following? A. Command hallucination B. Gustatory hallucination C. Cognitive distortion D. Somatic delusion

A. Command hallucination

nurse is teaching a client who has a new prescription for diazepam. Which of the following information should the nurse include in the teaching? A. Diazepam can cause drowsiness. B. This medication must be swallowed whole. C. It is important to avoid foods that contain tyramine. D. Grapefruit juice inactivates this medication.

A. Diazepam can cause drowsiness.

A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply) A. Muscle spasms of the neck B. Fidgeting behavior C. Blurred vision D. Tremors of the hands E. Sexual dysfunction

A. Muscle spasms of the neck B. Fidgeting behavior D. Tremors of the hands

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors? A. The client has borderline personality disorder B. The client has a parent who has dependent personality disorder C. The client has a history of bulimia nervosa D. The client recently received a promotion at work

A. The client has borderline personality disorder

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? A. The client runs 4 miles outdoors every afternoon. B. The client drinks 2 liters of liquids daily. C. The client eats 2 to 3 gm of sodium-containing foods daily. D. The client eats foods high in tyramine.

A. The client runs 4 miles outdoors every afternoon.

A nurse is reviewing the chart of a client who has dissociative amnesia. Which of the following should the nurse expect? A. The client was seriously injured while under the influence of alcohol. B. The client has a history of panic attacks. C. The client chose to drop out of college a few months ago. D. The client works a stressful job at an international bank.

A. The client was seriously injured while under the influence of alcohol. A traumatic event that causes stress is a trigger for dissociative amnesia.

A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check the see that which of the following tests have been completed? A. Thyroid hormone assay B. Liver function tests C. Erythrocyte sedimentation rate D. Brain natriuretic peptide

A. Thyroid hormone assay

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 animals

Complications of First-Generation Antipsychotics (Haldol)

Agranulocytosis, anticholinergic effects (dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia), EPS, pseudoparkinsonism, akathisia, tardive dyskinesia, neuroendocrine effects, neuroleptic malignant syndrome, orthostatic hypotension, sedation, seizures, severe dysrhythmias, sexual dysfunction, skin effects, liver impairment

Religiosity

An obsession, preoccupation, or excessive demonstration of religious ideas and behaviour (e.g., an individual who is unable to carry on a conversation due to his/her preoccupation w/ praying; a person who stops traffic to stand in the street and pray for forgiveness; or a person who is unable to answer a simple question w/o reference to scripture, God, or religion.).

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take? Act to the client as if the hallucination is real Instruct the client to argue with the voices that are a part of the hallucination. Ask the client direct questions about the hallucination. Tell the client that the hallucination is not a part of reality.

Ask the client direct questions about the hallucination.

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take? Ask the client to identify the bomb in the room. Initiate disaster protocols per facility policies and procedures. Assess the client for evidence of a perceptual disturbance. Convince the client that there is no bomb in their room.

Assess the client for evidence of a perceptual disturbance.

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

Projection

Attributing one's unacceptable thoughts and feelings onto another who does not have them

A nurse is in the working phase of a therapeutic relationship w/ a client who has methamphetamine use d/o. Which of the following actions indicates transference behavior? A. The client asks the nurse if they will go out to dinner together B. The client accuses the nurse of being controlling just like an ex-partner C. The client reminds the nurse of a friend who dies from substance toxicity D. The client becomes angry and threatens to engate in self harm

B

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect B. Intentionally causing someone to fall is an example of physical violence C. Striking a sexual partner is an example of sexual violence D. Failure to provide a stimulating environment for normal development is emotional abuse

B

A nurse is speaking w/ a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "you seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview w/o comment on the client's behavior

B

A nurse is involved in a serious and prolonged mass casualty incident in the ED. Which of the following strategies should the nurse use to help prevent developing a trauma related d/o? (SATA) A. Avoid thinking about the incident when it is over. B. Take breaks during the incident for food/ water C. Debrief w. others following the incident D. Avoid displays of emotion in the days following the indicent E. Take advantage of offered counseling

B C E

A nurse is performing an admission assessment for a client who has delirium r/t an acute UTI. Which of the following findings should the nurse expect? (SATA) A. History of gradual memory loss B. Family reports personality changes C. Hallucinations D. Unaltered LOC D. Restlessness

B C E

A nurse is planning care for a client who has bipolar d/o and is experiencing a manic episode. Which of the following interventions should the nurse include in the POC? (SATA) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client concerns E. Use a firm approach w/ communication

B C E

A nurse is planning group therapy for clients dealing w/ bereavement. Which of the following activities should the nurse include in the initial phase? (SATA) A. Encourage the group to work toward goals. B. Define the purpose of the group C. Discuss termination of the group D. Identify informal roles of members w/i the group E. Est. an expectation of confidentiality w/i the group

B C E

A nmurse is performaing an admission assessment of a client who has bulimia nervosa w/ purging behaviour. Which of the following is an expected finding? (SATA) A. Amenorrhea B. Hypokalemia C. Yellowing of the skin D. Slightly elevated body weight. E. Presence of lanugo on the face

B D

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassultive stage of violence? (SATA) A. Lethargy B. Defensive responses to questions c. Disorientation D. Facial grimacing E. Agitation

B D E

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following findings are expected for this d/o? (SATA) A. Fear of being alone B. Substance use C. Weight gain D. Irritability E. Aggressiveness

B D E

A nurse is planning a peer group discussion about the DSM-5. Which of the following info is appropriate to include in the discussion? (SATA) A. The DSM-5 includes client edu handouts for mental health d/o B. The DSM-5 establishes diagnostic criteria for individual mental health d/o C. The SDM-5 indicates recommended pharmacological tx for mental health d/o D. The SDM-5 assists nurses in planning care for client's who have mental health d/o E. The DSM-5 indicates expected assessment findings of mental health d/o

B D E

A nurse is providing teaching to the family of a client who has a substance use d/o. Which of the following stmnts by a family member indicates an understanding of the teaching? (SATA) A. "We need to understand that our sibling is responsible for their d/o" B. "Eliminating codependent behavior will promote recovery" C. "Our sibling should participate in an Al-Anon group to assist w/ recovery" D. "The primary goal of treatment is abstinence from substance use" E. "Our sibling needs to discuss personal feelings about substance use to help w/ recovery"

B D E

A nurse is caring for a client who is experiencing a crisis. Which of the following meds might the provider prescribe? (SATA) A. Litium carbonate B. PAroxetine C. Risperdone D. Haloperidol E. Lorazepam

B E

A nurse is working in an ED and assessing a preschool-aged child who report abd pain. Which of the following findings should alert the nurse to possible abuse? (SATA) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abd rebound and tenderness E. Areas of ecchymosis on torso

B E

A nurse is providing teaching for a client who has schizophrenia and a new prescription for fluphenazine. Which of the following information should the nurse provide? A. "This medication might turn urine your orange." B. "Sleepiness should subside within a week." C. "Stop the medication if hypotension occurs." D. "A low-grade fever is expected with first doses."

B. "Sleepiness should subside within a week."

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? A. Tell the client that he must talk less or he will be removed from the meeting. B. Ask group members to discuss their feeling about this client's monopolizing behavior. C. End the group meeting and take the client aside to discuss his behavior. D. Focus on other group members and ignore the client who is doing all the talking.

B. Ask group members to discuss their feeling about this client's monopolizing behavior. This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.

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? A. Fluvastatin B. Carbamazepine C. Lorazepam D. Propranolol

B. Carbamazepine

A charge nurse enters a client's room and observes an assistive personnel (AP) slapping an older adult client. After moving the client to safety, which of the following actions is the charge nurse's priority? A. Complete an incident report. B. Determine if the client has been physically harmed. C. Provide emotional support to the client. D. Discipline the AP.

B. Determine if the client has been physically harmed. The greatesy risk to this client is injury. Therefore, the priority intervention the charge nurse should take is to determine id the client has injuries that need attention.

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care? A. Provide a stimulating environment. B. Have consistent unit routines. C. Discourage daytime napping. D. Schedule daily seclusion times.

B. Have consistent unit routines.

A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? A. The program will help the client accept responsibility for his disorder. B. The client should obtain a sponsor before discharge for an increased chance of recovery. C. The client will need to identify individuals who have contributed to his disorder. D. The program will need a prescription from the client's provider prior to attendance.

B. The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client to secure a sponsor because the client-sponsor relationship has been shown to increase program attendance and chances of recovery.

Characterized by instability of affect, identity, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment; often self-injurious and potentially suicidal; ideas of reference are common; often accompanied by impulsivity

Borderline Personality Disorder (BPD)

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me." Which of the following actions should the nurse take? A. Keep the client's communications confidential, but talk to the client daily, using therapeutic communication to convince them to admit to hiding the knife. B. Keep the client's communication confidential, but watch the client and their roommate closely C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others D. Report the indicent to the health care team, but do not inform the client of the intention to do so.

C

A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression. B. Performing screenings for depression at community health programs. C. Establishing rehabilitation programs to decrease the effects of depression. D. Providing support groups for clients at risk for depression

C

A nurse in an acute mental health facility is planning for a client who has severe mental illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care? A Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visiting a community mental health center on a daily basis

C

A nurse in an emergency mental heath facility is caring for a group of clients. The nurse should identify that which of the following clients requires temporary emergency admission? A. A client who has schizophrenia w. delusions of grandeur B. A client who has manifestations of depression and attempted suicide a yr ago C. A client who has borderline personality d/o and assaulted a homeless man w/ a metal rod D. A client who has bipolar d/o and paces quickly around the room while talking to themselves

C

A nurse is assisting w/ a systematic desensitization for a client who has extreme fear of elevators. Which of the following actions should the nurse implement w/ this form of therapy? A. Demonstrate riding in an elevator, and then ask the client to imitate the behaviour B. Advise the client to say "stop" out loud every time they begin to feel an anxiety response r/t an elevator. C. Gradually expose the client to an elevator while practicing relaxation techniques D. Stay w/ the client in an elevator until the anxiety response diminishes

C

A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. The nurse discusses the client's weight loss during a health care team meeting. B. The nurse examines their own personal feelings about clients who have anorexia nervosa C. The nurse asks the client about personal body image perception D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents.

C

A nurse is caring for a client who was recently sexually assaulted. The client states, "II never should have been out on the street alone at night." Which of the following responses should the nurse mane? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C. "You believe this wouldn't have happened if you hadn't been out alone?" D. "Why do you feel that you should not have been alone on the street at night?"

C

A nurse is leading a peer group discussion about the indications for electroconvulsive therapy (ECT). Which of the following is appropriate to include in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysthymic disorder

C

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file B. Instruct the client's partner to offer finger foods to increase oral intake. C. Provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.

C

A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements by the nurse is appropriate? A. "You and a group of other clients will meet to discuss your treatment plans." B. "Community meetings have a specific agenda that is established by staff." C. "You and the other clients will meet with staff to discuss common problems." D. "Community meetings are an excellent opportunity to explore your personal mental health issues."

C

A nurse is planning a staff education program on substance use in older adults. Which of the following info should the nurse include in the presentation? A. Older adults require higher doses of substance to achieve a desired effect B. Older adults commonly use rationalization to cope w/ a substance use d/o C. Older adults are at an increased risk for substance use following retirement D. Older adults develop substance use to mask manifestations of dementia

C

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching? A. "I will report any loss of appetite." B. "Increased flatulence is an indication of toxicity." C. "Vomiting is an indication of toxicity." D. "I will call my provider if I experience any headaches."

C. "Vomiting is an indication of toxicity."

During the morning rouns, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take? A. Ask the client to identify the bomb in the room. B. Initiate disaster protocols per facility policies and procedures. C. Assess the client for evidence of a perceptual disturbance. D. Convince the client that there is no bomb in her room.

C. Assess the client for evidence of a perceptual disturbance. The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions).

A nurse in substance abuse is assessing a client who recently started taking disulfiram. The client reports having discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the client's distress? A. The client demonstrated an allergic response to the medication. B. The client experienced a common side effect to the medication. C. The client consumed alcohol while taking the medication. D. The client consumed alcohol while taking the medication.

C. The client consumed alcohol while taking the medication.

A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client indicates successful use of guided imagery? A. "I consciously decrease my breathing rate when I feel anxious." B. "I am riding my bike around the neighborhood every day." C. "I find at least one positive thing in situations that upset me." D. "I imagine myself lying on a quiet beach when I start to feel anxious."

D. I imagine myself lying on a quiet beach when I start to feel anxious." Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using guided imagery.

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? Prior physical health followed by the need for two surgeries within the last three months. Obsession over a fictitious defect in physical appearance. Sudden unexplained loss of peripheral sensation. Constant worry about the undiagnosed presence of an illness.

Constant worry about the undiagnosed presence of an illness.

Items not permitted in certain location (inpt mental health unit, jail, etc.) but must be fairly easy to smuggle in (such as wepons, items that could be made into a weapon, street drugs, cigarettes, lighters and matches, etc.) .

Contraband

A nurse educator is discussing community mental health with a group of nursing students. Which of the following sites should the educator identify as a source of secondary prevention? Day care center Outpatient rehabilitation center Community recreational center Crisis center

Crisis center

A charge nurse in discussing TMS w/ a newly licensed nurse. Which of the following stmts by the newly licensed nurse indicates an understanding of the teaching? A. "TMS is indicated for clients who have schizophrenia spectrum d/o" B. "I will provide postanesthesia care following TMS" C. "TMS treatments usually last 5-10 minutes" D. "I will schedule the client for TMS treatments 3-5 x a week for the first several weeks

D

A nurse in a long-term care facility is caring for a client who has major neurocognitive d/o and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside w/o a staff member." C. "Why would you want to leave? Aren't you happy w/ your care." D. "I am your nurse. Let's walk together to your room."

D

A nurse in an acute mental health facility is planning care for a client who has dissociative fuge. Which of the following interventions should the nurse add to the POC? A. Teach the client to recognize how stress brings on a personality change in the client. B. Repeatedly present the client w/ information about past events C. Make decisions for the client regarding routine daily activities D. Work w/ the client on grounding techniques

D

A nurse is caring for a client who has bipolar d/o. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior B. Admin prescribed meds as scheduled C. Provide the client w/ step-by-step instructions during hygiene activities D. Monitor the client for escalating behavior

D

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following stmts by the client to the coworker indicates client understanding? A. "You should really complete your own work. I don't think it's right to expect me to complete your responsibilities." B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities." C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor." D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

D

A nurse is collecting an admission history for a client who has acute stress d/o (ASD). Which of the following client behaviors should the nurse expect? A. The client remembers many details about the traumatic incident. B. The client expresses heightened elation about what is happening. C. The client remembers first noticing manifestations of the d/o 6 weeks after the traumatic incident occured. D. The client expresses a sense of unreality about the traumatic incident.

D

A nurse is conduction group therapy w/ a group of clients. Which of the following stmts made by the client is an example of aggressive communication? A. "I wish you would not make me angry" B. "I feel angry when you leave me" C. "It makes me angry when you interrupt me" D. "You'd better listen to me"

D

A nurse is providing teaching for a client who is scheduled to receive ECT for the tx of MDD. Which of the following client stmts indicates understanding of the following? A. "It is common to treat depression w/ ECT before trying meds." B. 'I can habe my depression cured if I receive a series of ECT tx." C. "I should receive ECT once a wk x 6 wks." D. "I will receive a muscle relaxant to protect me from injury during ECT."

D

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? A. Grandeur B. Flight of ideas C. Erotomania D. Ideas of reference

D. Ideas of reference

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? A. Administer phenytoin 30 minutes prior to the procedure. B. Instruct the client to expect a headache following the procedure. C. Place the client in four point restraints prior to the procedure. D. Monitor the client's cardiac rhythm during the procedure.

D. Monitor the client's cardiac rhythm during the procedure. The seizure induced during ECT can stress that client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram.

A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions should the nurse identify as the priority? A. Decrease distractions during meal times. B. Provide positive feedback when the child completes a task. C. Clearly identify consequences for unacceptable behavior. D. Remove unnecessary equipment from the child's surroundings.

D. Remove unnecessary equipment from the child's surroundings. The risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings.

A home-health nurse is assessing a client who has obsessive-compulsive disorder (0oCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following? Decrease anxiety. Prevent aggressive and impulsive behaviors. Manipulate others. Decrease the time available for interaction with people.

Decrease anxiety.

A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions? Denial Displacement Projection Undoing

Denial

A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mm Hg and a temperature of 39.9° C (103.8° F). Which of the following actions should the nurse take first? Administer phentolamine 5 mg IV to the client. Apply a hypothermic blanket to the client. Determine the client's prescribed medication regimen. Initiate IV access for the client.

Determine the client's prescribed medication regimen.

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply.) Diagnosis of schizophrenia Age greater than 55 Bachelor's degree Male gender Recent marriage

Diagnosis of schizophrenia Age greater than 55 Male gender

A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client? Dialectical behavior therapy Behavioral contract Bibliotherapy Safety plan

Dialectical behavior therapy

Alcohol abstinence Medications

Disulfiram, Naltrexone, Acamprosate

Lithium interactions

Diuretics, NSAIDS, Anticholinergics (antihistamines, tricyclic antidepressants)

When speaking to someone who is grieving....

Do NOT project own feelings

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.

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? Emotional lability Self-sacrificing Suspicious of others Grandiosity

Emotional lability

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care? Provide a stimulating environment. Have consistent unit routines. Discourage daytime napping. Schedule daily seclusion times.

Have consistent unit routines.

Clinical picture of parents to abused children

Emotionally immature; needy; incapable of meeting own needs; minimal parenting knowledge, skills; view children as property; cycle of family violence, adults raised (adults as victims of abuse frequently abuse their own children)

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? Have the client participate in a morning aerobics group. Encourage frequent rest periods throughout the day. Provide a distraction such as television at night. Offer the client hot chocolate at bedtime.

Encourage frequent rest periods throughout the day.

PTSD

Exposure to traumatic events causing anxiety, detachment and other manifestations about the event for longer than 1 mo following the event. Sx can last for years

A nurse is caring for a client who has a recent nurse about expected manifestations. The nurse diagnosis of mild Alzheimer's disease. The client's partner asks the should teach the partner to expect which of the following manifestations to occur first? Inability to recognize family members Chooses clothing that is inappropriate for the weather Exhibits a change in personality Frequently misplaces objects

Frequently misplaces objects

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.

Delusion of thought insertion (ideas of influence)

the belief that thoughts are placed into one's mind by outside people or influences

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? Advise the client to take frequent sips of water. Instruct the client to avoid driving during initial therapy. Consult a dietitian for a calorie-controlled diet plan. Recommend that the client exercise regularly.

Instruct the client to avoid driving during initial therapy.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? Raise the pitch of the voice when speaking to the client. Begin the interview by explaining the plan of care. Interview the client in a private setting. Ask the client to complete a detailed questionnaire.

Interview the client in a private setting.

A nurse is assessing a client who has schizophrenia. Which of the following behaviors should the nurse anticipate? Periods of elation with unusual talkativeness Preoccupied with folding clothes Invents words that have no meaning Recurrent thoughts of past trauma

Invents words that have no meaning

A nurse is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse plan to take? Prevent the client from performing compulsive behavior. Investigate what situations precipitate anxiety. Encourage avoidance of situations that increase anxiety. Teach the client that compulsive behavior is excessive.

Investigate what situations precipitate anxiety.

How can nurses handle disenfranchised grief?

Keep loved ones close; Utilize resources and programs

Euphoric (or expansive) mood or Euphoria

Lack of restraint in expressing one's feelings, frequently with an overvaluation of one's significance or importance.

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? Provide a cognitively stimulating environment. Rotate staff to prevent caregiver role strain. Limit the client's choices for daily activities. Use confrontation to manage negative behavior.

Limit the client's choices for daily activities.

GI distress - nausea, diarrhea, abdominal pain -Advise client that GI distress is usually transient -Administer med with meals or milk Fine hand tremors - can interfere with purposeful motor skills and can be exacerbated by factors (stress and caffeine) -Administer beta-adrenergic blocking agents (propranolol) -Adjust dosage to be as low as possible, give in divided doses, or use long-acting formulation -Advise client to report an increase in tremors, which could be a manifestation of toxicity Polyuria, mild thirst - use a potassium-sparing diuretic (spironolactone) -Maintain adequate fluid intake by consuming at least 1.5-3L/day fluid from beverages and food sources Weight gain - assist client to follow a healthy diet and regular exercise regimen Renal toxicity - Monitor I&O, adjust dosage and keep dose at lowest level necessary, assess baseline Bun and creatinine, and monitor kidney function periodically Goiter & Hypothyroidism - with long-term treatment -Obtain baseline T4 & T3 & TSH levels prior to starting treatment, then annually -Administer levothyroxine -Monitor for indications of hypothyroidism (cold, dry skin; decreased HR, weight gain) Bradydysrhythmias, hypotension, and electrolyte imbalances -maintain adequate fluid and sodium intake

Lithium adverse effects and nursing interventions/client education

A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take? Identify other housing options and sources of transportation. Notify the facility chaplain to request scheduling an appointment. Confirm that everything will be all right because belongings can be replaced. Maintain eye contact with client and summarize the client's feelings.

Maintain eye contact with client and summarize the client's feelings.

A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 months. Which of the following interventions should the nurse take? Make a contract with the client not to drive over the speed limit. Call the local police and alert them to the client's car license plate number and the make and model of her car. Ask the client to "hand over the keys" to you, and tell her that now she must use a cab or other public transportation until your next session. Inform the client that she cannot drink and drive.

Make a contract with the client not to drive over the speed limit.

an unstable mood that is elevated, expansive, or irritable; delusions, and poor judgement are present; The person experiences marked impairment in social, occupational, and interpersonal functioning

Mania

Bipolar Behaviors

Mania: abnormally elevated mood, which can also be described as expansive or irritable; usually requires hospitalization. Manic episodes last at least 1 week. Hypomania: A less severe episode of mania that lasts at least 4 days accompanied by three or more manifestations of mania. Hospitalization is not required, and the client who has hypomania is less impaired. Hypomania can progress to mania. Rapid cycling: Four or more episodes of hypomania or acute mania w/i 1 yr and associated w/ increased recurrence rate and resistance to tx.

-Use active listening to demonstrate willingness to help, and use specific communication techniques (open-ended questions, giving broad openings, exploring, seeking clarification) _provide a calm presence, recognizing client's distress -evaluate past coping mechanisims - explore alternatives to problem solving situations -encourage participation in activities, such as exercise that can temporarily relieve feelings of inner tension

Mild-to-Moderate Nursing Interventions

Autism Behaviors

Presents early childhool (18 mo - 3 yrs) -boys 5x more likely than girls -little eye contact -few facial expressions -limited gestures to communicate -limited capacity to relate to peers or parents -lack of spontaneous enjoyment -apparent absence of mood or affect -inability to engage in play or make-believe w/ toys -little intelligible speech -stereotyped motor behaviors -genetic link - controversy to MMR vaccine -tendency to improve w/ language skills -traits persist into adulthoold -Goal: reduce behavioral sx, promote learning and development, special education, language therapy, meds for target sx.

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? Promote the use of music to compete with the client's auditory hallucinations. Inform the client that the auditory hallucinations are not real. Avoid asking the client if they are experiencing auditory hallucinations. Instruct the client on the use of voice recognition regarding the auditory hallucinations.

Promote the use of music to compete with the client's auditory hallucinations.

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? Controls anger outbursts to avoid being placed in seclusion No longer exhibits a fear of social or public situations Refrains from manipulating others to earn dining room privileges fe Imitates the therapist's use of a relaxation technique

Refrains from manipulating others to earn dining room privileges

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? Warn the client that further disruptions will result in seclusion. Ignore the client's behavior, realizing it is consistent with her illness. Set limits on the client's behavior and be consistent in approach. Ask the client to recommend consequences for her disruptive behavior.

Set limits on the client's behavior and be consistent in approach.

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.

pressured or forced sexual contact, including sexually stimulated talk, or actions, inappropriate touching or intercourse, incest, human sex trafficking, female genital mutilation, and rape

Sexual Assault

A nurse is caring fr a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? Succinylcholine will enhance the therapeutic effects of this treatment Succinylcholine is a muscle paralyzing-agent that will decrease muscle movement during the procedure so the client is less likely to be injured Succinylcholine will decrease 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 a muscle paralyzing-agent that will decrease muscle movement during the procedure so the client is less likely to be injured

Self- directed actions that result in nor injury or minor injury but were done in such a way that others would interpret the act as suicidal behavior (e.g. minor scratches on the wrist w/ a plastic knife)

Suicide Attempts

A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse's assessment priority? Coping abilities Support systems Suicide risk Psychiatric history

Suicide risk

Silent rape reaction behaviors

Survivor does not report or tell anyone of the sexual assault, including fam, friends, or authorities. Abrupt changes in relationships. Nightmares. Increased anxiety during interview. Marked change in sexual behavior. Sudden onset of phonic reactions. No verbalization of the occurrence of sexual assault

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their 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 the environment. Tell the client that their partner is deceased. Talk with the client about activities they enjoyed with their partner.

Talk with the client about activities they enjoyed with their partner.

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the 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.

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? The client is exhibiting echolalia. The client reports command hallucinations. The client reports loss of motivation. The client is exhibiting blunted affect.

The client reports command hallucinations.

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the findings indicates the client is at risk for suicide? The client has begun playing basketball with several other clients during the past month. The client identifies with problems expressed by other clients. The client's behavior has become impulsive in the past few weeks. The client states she wants to go home to be with her children and partner.

The client's behavior has become impulsive in the past few weeks.

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization? Total body fat 8.7% Potassium 3.6 mEq/L Temperature 35.8° C (96.4 F) Heart rate 54/min

Total body fat 8.7%

reaction formation (defense mechanism)

Unacceptable feelings or behaviors are controlled or kept out of awareness by overcompensating or demonstrating. Overcompensation or demonstrating the opposite behavior of what is felt.

Client education on abuse

Understand expected growth and development patterns for children; parenting classes can be helpful, develop skills to assist w/ problem solving (assertiveness training); find ways to manage stress in a positive way (Mediation or relaxation); Consider external chjanges that can help reduce stress (a career change or moving)

Types of Bipolar Disorder

bipolar I: major depression and mania; at least 1 episode, alternating w/ MDD bipolar II: major depression and hypomania (excessive energy); 1 or more episodes alternating w/ MDD cyclothymia: periods of dysthymia and hypomania lasting at least 2 years; usually begins in adolescents/early adulthood

PTSD following sexual assault

can occur beyond month after attack; long-term psychological effects of sexual assault include: reliving the event (flashbacks, recurrent dreams, thoughts) increased activity (visiting friends frequently or moving residence) hyperarousal and increased emotional responses Avoidance, fears, and phobias Difficulties with daily functioning, low self-esteem, depression, sexual dysfunction, and somatic reports (headache or fatigue)

Irritable mood or irritability

easily annoyed or angered; responding readily, or to an abnormal degree to stimulus

Hypomania

elevated mood w/ sx less severe than those of mania; the person does not experience impairment in reality, nor do the sx markedly impair social, occupational, or interpersonal functioning

Blunted Affect (constricted, flat, or dull affect)

emotions that are diminished in range and intensity; absence of emotion expression

Illness Anxiety d/o- expected findings

excessive anxiety that a serious illness is present or will be acquired. This anxiety is present for > 6 mos though the actual illness the client fears can change. preoccupation w/ performance of behaviors that are health-related (performing a daily breast self-exam due to fear of breast cancer). Some clients have illness anxiety d/o that is the health-seeking type while others exhibit care-avoidant type

psychomotor agitation

excessive motor and cognitive activity, usually nonproductive and in response to inner tension

Auditory hallucinations

hearing noices or sounds most commonly in the form of voices. Hallucinations can include complete conversations between 2 or more people about the person who is hallucinating. They can include audible t houghts in which the person hears voices that are speaking what the pt is thinking. They can include commands that tell the person to do something that is sometimes harmful or dangerous, although not all auditory hallucinations are negative. (Auditory are the most common type of hallucinations) A specific type of auditory hallucination directing a person to do something is referred to as command hallucination. These must be carefully assessed as they may be commanding the person to hurt self or others

Expected findings of an aggressive or angry pt

hyperactivity such as pacing, restlessness, hypersensitivity, easily offended, eye contact that is intense or no eye contact at all, facial expressions (frowning, grimacing), body language (clenching fists, waving arms), rapid breathing, aggressive postures (leaning forward, appearing tense) verbal cues (loud, rapid talking, yelling, shouting), drug or alcohol intoxication

Disease conviction or disease phobia

illness anxiety d/o (Hypochondriasis)

Delirium s/sx

impairments in memory, judgment, ability to focus and ability to calculate, which can fluctuate throughtout the day. Disorientation and confusion often worse at night and early morning.

Dementia s/sx

impairments in memory, judgment, speech (aphasia), ability to recognize familiar objects (agnosia), executive functioning (managing daily tasks), and movement (apraxia), impairments do not change throughout the day. LOC is usually unchanged. restlessness and agitation are common, sundowning can occur, personality change is gradual, VS are stable unless other illness is present

ADHD s/sx

inattentiveness, over-activity, impulsiveness, persistent pattern of inattention and/or hyperactivity amd impulsivity; often dx when child starts school; fidgety, noisy, disruptive, unable to complete tasks, failure to follow directions, blurting out answers, lost or forgotten homework, possible ostracize and ridicule by others, no one tx is effective for all Goal- managing sx, reducing hyperactivity and impulsivity, increasing child's attention

Advanced indications of lithium toxicity

lithium levels 2.0-2.5 mEq/L manifestations: extreme polyuria of dilute urine, tinnitus, giddiness, jerking movements, blurred vision, ataxia, seizures, severe hypotension and stupor leading to coma, and possible death from respiratory complications nursing actions: admin an emetic to alert clients, or admin gastric lavage, urea, mannitol, or aminophylline may be prescribed to increase rate of excretion

Lithium Level less than 1.5 mEq/L

manifestations: diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremors, slurred speech, lethargy nursing action: instruct client that manifestations at low levels often improve over time

Tardive Dyskinesia (TD)

manifestations: Late EPS's, which can require months to years of medication therapy for TD to develop, involuntary movements of the tongue and face, such as lip smacking and tongue fasciculations, involuntary movements of arms, legs and trunk Nursing actions: evaluate client after 12 mos of therapy and then every 3 mos. If TD appears, dosage should be lowered or the client should be switched to a second-generation antipsychotic agent. Once TD develops, it usually does not decrease even with discontinuation of the drug. No reliable treatment for TD. Teach client that purposeful muscle movements help to control the involuntary TD.

Approching angry and aggressive pts

observable behaviors that are performed on an unconscious level to reduce anxfiety and tension: (e.g., excessive screaming, hitting, cursing, verbally defiant language)

Adventitious crisis

occurrence of natural disasters, crimes, or national disasters people in communities with large-scale psychological trauma caused by natural disasters

Situational/external crisis

often unanticipated loss or change experienced in everyday, often unanticipated, life events (divorce, job change)

Severe anxiety

perceptual field is greatly reduced with distorted perceptions; learning and problem solving DO NOT occur; functioning is ineffective; confusion, feelings of impending doom, hyperventilation, tachycardia, withdrawal, loud and rapid speech, aimless activity; not able to take direction from others

Anorexia Nervosa Characteristics

preoccupied with food, rituals of eating, along with a voluntary refusal to eat condition occurs most often in female clients from adolescence to young adulthood onset can be associated with a stressful life event such as college compared to clients who have restricting type, those who have binge-eating type/purging have higher rates of impulsivity and are more likely to abuse drugs and alcohol

Nursing actions for sexual assault clients

provide phone numbers for 24-hr hotlines for sexual assault survivors promote self-care activities, give instructions in writing because client might not be able to comprehend or remember verbal instructions Initiate referrals for needed resources or support services. Schedule follow-up visits at prescribed intervals after assault Emphasize importance of after care, as sexual assault clients historically have a poor compliance rate with follow-up visits

Flight of ideas

rapidly changing or disjointed thoughts

Time out

removing or disengaging a person from a situation so that he/she might: 1) regain self control and/or 2) not hurt self and/or others

Frustration causes in alzheimer's pts

repeatedly asking questions causes frustration- pt wants to remember and is unable to do so

Parental education for ADHD

rewards and consequences, consistent praise, time out, verbal reprimands Combination of meds +behavioral + psychosocial and educational interventions Stimulants- Methylphenidate (Ritalin), Amphetamine (Adderall), Lisdexamphetamine (Vyvanse) Antidepressants as second choice; every child is different; do not be judgemental of parents parenting choices; risk for injury; ineffective role performance

Intellectualization

separation of emotions and logical facts when analyzing or coping with a situation or event

A nurse observes a client on a mental health unit pushing on a locked unit door. Which of the following statements should the nurse make? A. "It appears as though you would like to open the door." B. "You will feel more comfortable after you've been here a while." C. "It is okay to not want to be here." D. "You really shouldn't be pushing on the door."

A. "It appears as though you would like to open the door." This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that she can describe thoughts and feelings related to that behavior.

A nurse is teaching a family member and a client who has a new diagnosis of Alzheimer's disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? A. "Take this medication in the evening at bedtime." B. "Expect this medication to reverse the effects of Alzheimer's disease." C. "If you miss a dose, double the next dose." D. "You can crush this medication in applesauce."

A. "Take this medication in the evening at bedtime." The client should take this medication in the evening at bedtime for optimal effectiveness.

A nurse is caring for a client who is experiencing alcohol withdrawal. The client has a heart rate of 110/min, blood pressure of 170/96 mm Hg, and temperature of 38.9 degrees Celsius( 102 degrees Fahrenheit). Client history and physical include that the client states he consumed alcohol 12 hours prior to admission and the client has a 2 pack/day smoking history. Client progress notes include bilateral tremors of the hands and finger, emesis of 30 mL bile-colored fluid, restlessness, unable to sit still, diaphoresis, and flushed skin. Which of the following medications should the nurse administer first? A. Diazepam 5 mg IV bolus B. Clonidine 0.1 mg transdermal patch C. Naltrexone 380 mg IM D. Bupropion 150 mg PO

A. Diazepam 5 mg IV bolus The greatest risk to the client who is experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations.

A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? A. St. John's wort B. Saw palmetto C. Echinacea D. Ginkgo

A. St. John's wort St. John's wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome.

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? A. The client needs excessive external input to make everyday decisions. B. The client demonstrates a dedication to his job that excludes time for leisure activities. C. The client adheres to a rigid set of rules. D. The client has difficulty starting new relationships unless he feels accepted.

A. The client needs excessive external input to make everyday decisions. Clients who have dependent personality disorder need excessive input from others to make everyday decisions.

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?

Assertive community treatment

A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis? A. "She works so hard at ballet. Will she still be able to perform?" B. "She won't let me take the trash from her room. I'm concerned about what she has in there." C. "She told me she was tired, so I did her chores for her today." D. "She is happier with her appearance now that she's lost some weight."

B. "She won't let me take the trash from her room. I'm concerned about what she has in there." The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother's statement indicates awareness of her daughter's behavior.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Orient the client to person, place, and time. B. Assist the client with deep-breathing exercises. C. Calm the client by using therapeutic touch. D. Have the client sit alone in a quiet room.

B. Assist the client with deep-breathing exercises. Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hours ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? A. Somnolence B. Blood pressure 154/96 mm Hg C. Pinpoint pupils D. Blood glucose 210 mg/dL

B. Blood pressure 154/96 mm Hg Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3 degrees Celsius (101 degrees Fahrenheit). It will be important for the nurse to rule out infection in the client who has a fever.

A nurse is planning prevention strategies for intimate partner abuse in the community. Which of the following strategies should the nurse include as a method of secondary prevention? A. Provide teaching about the use of positive coping mechanisms. B. Establish screening programs to identify at-risk clients. C. Refer survivors of intimate partner abuse to a legal advocacy program. D. Organize rehabilitation therapy for clients who have experienced intimate partner abuse.

B. Establish screening programs to identify at-risk clients. This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for intimate partner abuse in the community and take the necessary steps to address individual client needs.

A nurse assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? A. Rapid improvement in affect within 30-60 minutes after taking the medication. B. Greater risk of attempting suicide as affect and energy improve. C. Onset of frequent loose stools. D. Development of physiologic dependence on the medication.

B. Greater risk of attempting suicide as affect and energy improve. An initial response to amitriptyline can develop in one week. For a client who has been severely depressed with suicidal ideation, the energy to carry out a plan is more possible after 1 week of treatment.

A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hours ago following a motor vehicle crash. The clients admission blood alcohol level was 325 mg/dL . Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

Blood pressure 154/96 mm hg

A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who was hit for injuries.

C. Call for a team of staff members to help with the situation. The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to himself or others.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? A. Raise the pitch of the voice when speaking to the client. B. Begin the interview by explaining the plan of care. C. Interview the client in a private setting. D. Ask the client to complete a detailed questionnaire.

C. Interview the client in a private setting. The nurse should question clients in a private place when conducting interviews regarding client health.

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? A. Controls anger outbursts to avoid being placed in seclusion. B. No longer exhibits a fear of social or public situations C. Refrains from manipulating others to earn dining-room privileges. D. Imitates the therapist's use of a relaxation technique

C. Refrains from manipulating others to earn dining-room privileges. The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response.

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? A. Document the client's behavior every 8 hours. B. Limit the client's fluid intake to 50 mL/hour. C. Renew the prescription for the client every 4 hours. D. Toilet the client every 4 hours.

C. Renew the prescription for the client every 4 hours. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hours, for a maximum of 24 hours.

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? A. Weight gain B. Tinnitus C. Tachycardia D. Increased salivation

C. Tachycardia The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate.

A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization? A. Weight loss 10% of total body weight in 3 months. B. Potassium 3.8 mEq/L C. Temperature 35.6 degrees celsius (96.1 degrees Fahrenheit) D. Heart rate 54/minute

C. Temperature 35.6 degrees Celsius (96.1 degrees Fahrenheit) Severe hypothermia, a temperature lower than 36 degrees Celsius (96.8 degrees Fahrenheit) due to loss of subcutaneous tissue or dehydration, requires hospitalization.

A home nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? A. Increased confusion B. Sleep disturbances C. Cluttered environment D. Inappropriate dress

D. Inappropriate dress Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? A. Panic B. Moderate C. Severe D. Mild

D. Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety, The is when the client will be able to concentrate and process information.

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following places the client at the greatest risk for self-directed injury or injuring others? A. Inability to communicate with others B. Feeling of absence of self-worth C. Lack of motivation to perform daily tasks D. Command hallucinations

D. Command hallucinations A client who has schizophrenia and is experiencing command hallucinations can hear voices telling him to hurt himself or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self-directed injury or injuring others.

A nurse is caring for a client who has a recent diagnosis of Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? A. Inability to recognize family members B. Chooses clothing that is inappropriate for the weather C. Exhibits a change in personality D. Frequently misplaces objects

D. Frequently misplaces objects According to evidence-based practice, the nurse should identify that mild cognitive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has Alzheimer's disease. As the disease progresses, other manifestations of moderate and severe cognitive impairment will occur.

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? A. Allowing a client to choose which unit activities to attend B. Attempting alternative therapies instead of restraints for a client who is combative C. Providing a client with accurate information about his prognosis D. Spending adequate time with a client who is verbally abusive

D. Spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive care.

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? A. Amenorrhea B. Lanugo C. Cold extremities D. Tooth erosion

D. Tooth erosion A client who has bulimia nervosa is likely to have dental carries and tooth erosion caused by frequent exposure to gastric acid from vomiting.

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a nurse client relationship, which of the following actions should the nurse take first?

Inform the client that this admission is confidential.

A nurse is planning care for a client who has to undergo electroconvulsive therapy. Which of the following actions should the nurse include in the plan?

Monitor the clients cardiac rhythm during the procedure

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, " my roommate never sleeps and keeps me up, too."Which of the following actions should the nurse take?

Move the client who has bipolar disorder to a private room.

A nurse is discussing a 12 step program with a client who has alcohol use disorder and is in acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?

The client should obtain a sponsor before discharge for an increased chance of recovery.

A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (select all that apply.)

Occupational therapy Meal delivery services Physical therapy Home health services

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over the counter medications that the client reports taking should alert the nurse to a potential adverse reaction?

Phenylephrine

A nurse is Caring for a child who is taking methylphenidate. The nurse should monitor that child for which of the following findings as an adverse effect of methylphenidate?

Tachycardia

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at increased risk for depression?

The client has COPD