Final exam lecture test questions

No intervention is necessary at this time

A client has a lithium level of 1.2 mEq/L. Which of the following interventions by the nurse is indicated

Client arrives to the clinic near and appropriate jn appearance

A client receiving tricyclic antidepressants arrives at the mental health unit. Which observation would indicate that the client is following the medication plan correctly

Ensure the liner has swallowed their medication

A nurse caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?

air traffic controller

A nurse is discharging a client diagnosed with OCD. Which employment opportunity is most likely to be recommended by treatment team?

anxiety disorders childhood trauma

A nurse is discussing the factors for somatic symptom disorder with a new nurse. Which of the following risk factors should the nurse include? SATA

Offer concise explanations Establish consistent limits Use a firm approach with communication

A nurse is planning care for a patient who has bipolar disorder and is experiencing a manic episode. Which of the following interventions include in the plan of care? SATA

The client combines the drug with alcohol.

In which situation is a client at highest risk for lorazepam overdose?

"It will be difficult for me to avoid pepperoni"

The nurse has completed health teaching about dietary restrictions for a client taking a MAOi. The nurse will know the teaching has been effective by which of the following client statements?

Dental decay Loss of tooth enamel Electrolyte imbalances

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia. Which assessment findings should the nurse expect to bite? SATA

"You're having difficulty sleeping?"

The nurse visits a client at home. THe client states "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication?

weight gain and length

Which of the following side effects of lithium are frequent causes of noncompliance?

Auditory hallucinations Delusions of grandeur Severe agitation

A charge nurse is discussing manifestations of schizophrenia with a new nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first generation antipsychotics?

At the same time each evening

A clients medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose?

alcohol withdrawal delirium

A confused, tremulous, diaphoretic client with a short history of heavy drinking has a pulse of 120, respiration of 24, and BP 180/90. Which would be the suspected cause of these symptoms?

Hallucinations Diaphoresis Agitation

A nurse is assessing a client 4 hour after receiving an initial dose of fluoxetine (Prozac). Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? SATA

Imbalanced nutrition: less than body requirements R/T depressed mood

An anorexic cleint who was recently deserted by a spouse is admitted to an in-patient psych unit with a diagnosis of major depressive disorder. Which nursing diagnosis take priority at this time?

misinterpretation of stimuli

On an inpatient psych unit, a nurse is completing a risk assessment on a newly admitted client with increased levels of anxiety. The nurse would document which cognitive symptom expressed by the client?

Non stop physical activity and poor nutritional intake

The nurse assessed a client with the admitting diagnosis of bipolar, mania. Which client symptoms require the nurses immediate action?

Observing rigid rules and regulations

The nurse is caring for a client with anorexia. Which behavior is characteristics of this disorder and reflect anxiety management?

"What do you find difficult about this situation?"

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse?

Helping the client to examine dysfunctional thoughts and beliefs

When a client is admitted to an inpatient mental hosptial with the diagnosis of anorexic. The nurse plans care based on which purpose of this approach?

suspicion without justification

When assessing a client diagnosed with paranoid disorder the nurse might identify which characteristic behavior?

"I plan to jump from a secluded bridge after midnight"

Which client suicide plan would be considered most lethal?

A client prescribed Nardil and Prozac

Which situation would place a client at high risk for a life threatening hypertensive crisis?

types of drugs used

While the nurse is completing an initial interview with a client in the ER the client admits to recent drug use. Which area of assessment should take priority?

The client will verbalize and understanding of unit rules and consequences for infarctions by the end of shift.

a client diagnosed with an antisocial personality disorder has a nursing diagnosis of ineffective coping R/T parental neglect AEB "I broke the jerks arm, but he deserved it." Which short term outcome is appropriate for this client's problem?

"I am an angel compared to the rest of my family"

a client diagnosed with antisocial personality disorder, is given a nursing diagnosis of defensive coping R/T a dysfunctional family system AEB denial of obvious problems and belligerence. Which client statement would confirm this nursing diagnosis?

a previous suicide attempt access to lethal methods isolation impulsive or aggressive tendencies

which of the following factors places a client at high risk for a suicide attempt? SATA

"The client is at greatest risk for suicide during the first weeks of major depressive disorder episode"

A charge nurse is discussing the care of a client with major depressive disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

1.4 mEq/L

A client admitted to an inpatient psych unit following a manic episode is prescribed lithium 300mg bid. Which serum lithium level would the nurse expect at discharge?

Contact the clients health care provider

A client admitted voluntarily for treatment of anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?

conversion disorder

A client bus admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit and run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult?

Emphasize with the family member and communicate the need to gain information directly from the client

A client diagnosed with anorexia is forced into the ER department by a family member. During the intake assessment, this family member answers all the questions posed to the client. Which nursing intervention is appropriate at this time?

Monitor the client for suicidal ideations related to depressed mood

A client diagnosed with antisocial personality disorder is facing a 20 year prison sentence. The cleitn has been prescribed Zoloft for depressed mood. Which intervention takes priority

blurred vision and vomiting

A client diagnosed with bipolar has been taking lithium for 3 months. Which assessment data would make the nurse request a lithium level?

Use an indirect light source and turn off the television

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

the simultaneous need for and fear of intimacy

A client diagnosed with schizophrenia is experiencing emotional ambivalence. When the nurse edicates the client's family, which would best describe this symptom?

encourage exploration of the source of anxiety

A client diagnosed with somatization disorder. When planning care, which nursing intervention should be included?

Experiencing severe back pain has taken my mind off my pending divorce

A client diagnosed with somatization pain disorder is admitted to an in-patient psych unit. Which client statement would the nurse assess as evidence of primary gain?

Use open ended questions and silence

A client experiencing disturbed thought processes believe that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?

A structured program of activities in which the client can participate

A client is admitted to a mental health unit with a diagnosis of depression. The. Horse should develop a plan of care for the client that includes which intervention?

Assigning to the client a staff member who will remain with the client at all times

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action

Remind the client to have a serum level drawn 12 hours after taking a dose of Lithium

A client is discussing plans to have a serum Lithium level taken on discharge. To obtain an accurate serum level, which discharge teaching information should be included

The client dislikes the weight gain associated with antipsychotic therapy

A client is seen for frequent exacerbation of schizophrenia due to non adherence to mediation regimen. The nurse should assess for which of the following common contributors to nonadherence?

Do you feel afraid that people are trying to hurt you?

A client says to the nurse "the federal guards were sent to kill me" which is the best response by the nurse to the clients concern?

toxic

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse plans care based on which representation of this level?

rapid heart beat or anxiety

A client who had been taking buspirone for one month returns to the clinic for a follow up assessment. The nurse determines that the medication is effective if the absence of which manifestation occurred

"You've been feeling like a failure for a while?"

A client with a diagnosis of depression who has attempted suicide says to the nurse "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication?

the principle of nonmaleficence the principle of least restrictive treatment the principle of beneficence the principle of negligence

A hypomanic client diagnosed with bipolar disorder 2 chatters constantly and becomes disruptive in a group. THe client is forcibly placed in 4 point restraints. Which of the following principles were violated in this scenario. SATA

"Current medications include Furosemide for congestive heart failure."

A nurse admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the clients caregiver, which of the following statements is the priority to report to the doctor?

"I am here to provide care and cannot accept this from you"

A nurse caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give you my money to you." Which of the following responses should the nurse make?

Administer the next dose of lithium carbonate as scheduled

A nurse caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium, the clients lithium blood level is 1.2. Which of the following actions should the nurse take?

the client is in the prealcoholic phase of drinking patterns and has a biological predisposition to alcoholism

A nurse is assessing a client being treated for a fractured leg. History reveals that the client's father and grandfather died of complications of alcoholism. The client admits to using alcohol to reduce stress. Which statement is most likely true?

Fine tremors of both hands Vomiting Restlessness

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? SATA

OCD History of childhood abuse avoidance of health care providers depressive disorder

A nurse is assessing a client who has illness anxiety disorder. Which of the following are expected for this disorder? SATA

Attempts to convince other clients to relinquish their belongings Blames others for personal past and current problems

A nurse is assisting with a court ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? SATA

Conducting a suicide risk screening Educating high school tees about suicide prevention Teaching middle school educators about warning indicators of suicide

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention?

"I understand you have concerns about your weight, but first, let's talk about your recent accomplishments."

A nurse is caring for a client who bulimia and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make?

Disulfiram

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol?

Monitor the client for the escalating behavior

A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?

History of chronic bronchitis Recent death in clients family Family history of depression Personal history of panic disorder

A nurse is caring for a client who has major depressive disorder. Which of the following shoudk the nurse identify as a risk factor for depression? SATA

"When did you start hearing these things?" "it must be scary to hear voices" "Are the voices you hear telling you to hurt yourself?"

A nurse is caring for a client who has substance psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements shoudl the nurse make? SATA

"I will need to discontinue this medication slowly"

A nurse is caring for a client who is to begin taking fluoxetine (Prozac) for treatment of panic disorder. Which of the following statements indicates the client understands the use of this medication?

auditory hallucinations use of clang associations Delusion of persecution Constantly waiving arms

A nurse is completing admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms. SATA

It's efficacy

A nurse is instructing a client on taking lithium for bipolar disorder. The client will need to have blood draws every 2-3 days initially to determine what about the drug level?

Presence of manifestation for at least 2 years

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect?

Administer the medication in the morning Monitor for weight loss while taking this medication This medication blocks synaptic reuptake of serotonin in the brain

A nurse is teaching a child who has intermittent explosive personality disorder about a new prescription for fluoxetine. Which of the following should the nurse provider?SATA

Placing the client on one to one observation

A nurse working on an acute mental health unit is admitting a client who has a major depressive disorder and comorbid anxiety disorder. Which of the following actions in the nurses priority?

The client is experiencing a positive outcome exhibited by group attendance and communication with staff.

An adolescent diagnosed with major depressive disorder has a nursing diagnosis of social isolation. This client is currently attending groups and communicating with staff. Which statement evaluates this client's behavior accurately?

Ask the client about the amount of drug use and it's effect

The home health nurse visits a client at home and determines that this client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback

The nurse in a mental health unit plans to use which therapeutic communication techniques when communicating with a client? SATA

Get up slowly when changing positions

The nurse is administering risperidone to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client?

Avoid using a whisper voice in front of the client

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?

Provide authority, action, and participation

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?

Interrupt the client and offer to take her for a walk

The nurse is caring for a female client who has admitted to the mental health unit recently for anorexia. The nurse enters the room and notes that the client is engaged in rigorous push ups. Which nursing action is most appropriate?

Setting limits on the clients behavior

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the groups interactions. Which intervention should the nurse initially implement?

Lack of ability to cope effectively

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?

"I don't have a problem. It's your problem for misunderstanding."

The nurse is evaluating a client diagnosed with antisocial personality disorder. Which client statement is reflective of this diagnosis?

Hypertension, changes in level of consciousness, hallucinations

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium

Gastrointestinal dysfunction

The nurse is performing a follow up teaching session with a client discharged one month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of this medication?

Use of cofabukation

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?

writing

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be the most appropriate for this client?

One to one suicide precautions

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care

death of a loved one

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?

tardive dyskinesia

The nurse notes that a client with schizophrenia and receiving an antipsychotic mediation is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determine that the client is experiencing which medication complication?

"I have high estrogen levels, and that is why I am not having periods"

The nursing is teaching a 16 year old girl, diagnosed with anorexia, about the potential risk for osteoporosis. Which statement by the client may indicate a further indicates further teaching about osteoporosis is necessary?

Identifying anxiety producing situations

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting safe environment at home. Which is the most appropriate maintenance goal?

The client is aware at some point during the course of the disorder that the obsession or compulsions are excessive or unreasonable or both.

Which assessment data supports the diagnosis of OCD?

Monitor vital signs Provide a safe environment Address hallucinations therapeutically Provide reality orientation as appropriate

Which intervention are most appropriate for caring for a client in alcohol withdrawal? SATA

the right to refuse medication the right to expect treatment that does no harm. The right to know the truth about his or her illness The right to be treated equally

Which of the following rights are afforded to a client who is admitted to an inpatient psychiatric unit as a danger to self? SATA

Persons who are diagnosed at a younger age will more likely have a poorer outcome

Which of the following statements is most accurate regarding the age at onset of a mental illness such as schizophrenia