mental health 2

A school nurse is caring for an adolescent client who has a hx of depressive episode 1 yr ago. He appears withdrawn from social activities and his school performance is declining. What action should the nurse take first? a. initiate a structured daily schedule of activities b. conduct a suicide-risk assessment c. encourage the client to express his feelings in a journal d. ask teacher to monitor for other signs of depression

b. conduct a suicide-risk assessment

A nurse asks an older adult client, did you have any visitors yesterday? The client responds, yes, several members of my church chior came to see me. The nurse knows that only the client's daughter visited the day before. What cognitive impairment is the client demonstrating? a. perseveration b. confabulation c. apraxia d. agnosia

b. confabulation

A nurse is providing teaching to a client who has OCD and performs hand hygiene to decrease anxiety. What action by the nurse implements modeling as a behavioral intervention strategy? a. setting a time limit between episodes of hand washing b. demonstrating performance of hand hygiene at scheduled times c. telling the client to shout stop each time there is an urge to perform hand hygiene d. instructing the client to practice muscle relaxation when experiencing the urge to perform hand hygiene

b. demonstrating performance of hand hygiene at scheduled times

A nurse is assessing a client who has an anxiety disorder and is taking benzodiazepine. For what adverse effect should the nurse monitor the client? a. seizures b. dizziness c. polyuria d. insomnia

b. dizziness

A nurse is caring for a client who has dementia. What finding should the nurse expect? a. altered LOC b. impaired judgment c. rapid change in personality d. disturbances in perception

b. impaired judgment

A nurse is caring for a client who has panic disorder and is experiencing anxiety at the panic level. What action should the nurse take first? a. identify the cause of anxiety b. instruct the client to take slow, deep breaths c. teach the client how to use positive self-talk d. explain the physical manifestations of anxiety to the client

b. instruct the client to take slow, deep breaths

An ED nurse is assessing a client who has anxiety disorder. The client is flushed, perspiring profusely, and is experiencing palpitations. The client begins to scream, I am going to die! This is it! I am having a heart attack! the nurse should determine the client's level of anxiety to be? a. moderate b. panic c. severe d. mild

b. panic

A nurse is caring for a client who has acute delirium. What finding should the nurse expect? a. progressive deterioration of cognitive function b. rapid fluctuation in LOC c. loss of language ability d. absence of contributing factors to pinpoint cause of delirium

b. rapid fluctuation in LOC

A nurse is providing teaching to a client who has a new script for diazepam. What instructions should the nurse include in the teaching? a. expect this med to make you feel anxious b. this med can be habit-forming c. take this med on an empty stomach d. this med takes 2-3 weeks to reach full therapeutic effect

b. this med can be habit-forming

A nurse is providing discharge teaching for a female client who has an anxiety disorder and a new script for lorazepam. What instructions should the nurse include in the teaching? a. this med can safely be taking during pregnancy b. this med must be discontinued by gradual tapering over time c. an extra dose of this med can be taken at bedtime if you experience insomnia d. you should monitor your glucose levels closely while taking this med

b. this med must be discontinued by gradual tapering over time

A nurse is planning to administer a dose of lithium carbonat eto a client who has bipolar disorder. The lab report indicates that the client's current lithium level is 1.0. What action should the nurse take first? a. contact the provider for a dosage increase b. request a repeat of the lithium leve c. administer the medication d. prepare the client for gastric lavage

c. administer the medication

A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. What meal should the nurse provide for this client? a. spaghetti and meat balls, salad, apple pie b. beef and veggie stew, rice, vanilla pudding c. chicken nuggets, crackers with cheese sticks, cookie d. broiled fish fillets, stewed tomatoes, ice cream

c. chicken nuggets, crackers with cheese sticks, cookie

A nurse is providing d/c teaching for a client who has a new script for doxepin. What adverse effects should the nurse inform the client is associated with this medication? a. wt loss b. diarrhea c. drowsiness d. bradycardia

c. drowsiness

A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine fumarate. The nurse should instruct the client that what blood tests should be performed periodically? a. potassium b. uric acid c. glucose d. calcium

c. glucose

A nurse is assessing a client who has been taking an antipsychotic med for 6 years and the provider has started tapering off the dosage. The nurse should monitor the client for what manifestation of tardive dyskinesia? a. muscular weakness b. muscle spasms c. involuntary tongue protrusion d. uncontrolled eye rolling

c. involuntary tongue protrusion

A nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt and appears to be actively hallucintating. What should be the nurses priority assessment? a. perception of reality b. ability to follow directions c. physical needs d. mental status

c. physical needs

A nurse is providing teaching to a client who has a new script fo chlorpromazine. What statement should the nurse make? a. this med is a tricyclic antidepressant and will improve your mood b. this med is an opioid antagonist that blocks the pleasurable effects of alcohol c. this med is an antipsychotic that controls manifestations of schizophrenia d. this med is a cholinesterase inhibitor that slows the progression of dementia

c. this med is an antipsychotic that controls manifestations of schizophrenia

A nurse is assessing a client who has been taking thioridazine for several days. The client reports hand tremors, drooling, rigid extremities. What actions should the nurse take? a. reassure the client that these effects are expected b. administer diazepam c. encourage deep breathing and relaxation d. administer benztropine

d. administer benztropine

A nurse is assessing a client who has a psychotic disorder and a new script for haloperidol. The client is pacing in the hallway and states, I can't seem to sit still. What extrapyramidal side effect is the client likely experiencing? a. dystonia b. parkinsonism c. tardive dyskinesia d. akathisia

d. akathisia

A nurse is reviewing the health hx of a young adult client who has a depressive disorder. What factors should the nurse identify as increasing the client's risk for depression? a. client is an only child b. client lives in an urban setting c. client is married d. client is female

d. client is female

A nurse in an outpt mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. What action should the nurse take first? a. teach the client strategies to decrease hallucinations b. identify if the client is on antipsychotic meds c. distract the client from the hallucination d. explore what the voices are saying to the client

d. explore what the voices are saying to the client

A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. What finding should the nurse expect? a. bradycardia b. increased somnolence c. slurred speech d. headache

d. headache

A nurse in the ED is assessing a client who has cocaine intoxication. What finding should the nurse expect? a. pinpoint pupils b. drowsiness c. nystagmus d. hypervigilance

d. hypervigilance

A nurse is providing teaching to a client who has generalized anxiety disorder and a new script for buspirone. What statement by the client indicates an understanding of the teaching? a. this medication can cause dependence b. i should take a dose of my med when i start to feel anxious c. its important for me to take my med 30 min before bedtime d. i should expect to fell the full effect of my med in 2-4 weeks

d. i should expect to fell the full effect of my med in 2-4 weeks

A nurse is assessing a client who has schizophrenia. The client states, I need to get my gummamoshu from by my house. The nurse recognizes this statement as an example of what? a. flight of ideas b. echolalia c. perseveration d. neologism

d. neologism

A nurse in a mental health clinic is assessing a client who has a hx of mania. What finding indicates that the client is experiencing a relapse? a. weight gain b. ritualistic behavior c. anhedonia d. pressured speech

d. pressured speech

A nurse is providing teaching to a client who has a new script for phelezine. The nurse should teach the client that which of the following OTC meds can cause hypertensive crisis when taken with phenelzine? a. acetaminophen b. ranitidine c. naproxen d. pseudoephedrine

d. pseudoephedrine

A nurse is caring for a client who is taking a tricyclic antidepressant. What adverse effect should the nurse report to the provider immediately? a. dry mouth b. constipation c. drowsiness d. urinary retention

d. urinary retention

A nurse is caring for a client who has been unable to leave the house for the past 10 years without accompainment. What attempting to go out alone, the client becomes very anxious and must quickly return inside. The nurse should identify that the client is exhibiting what disorder? a. agoraphobia b. PTSD c. panic disorder d. OCD

a. agoraphobia

a nurse is caring for a client who has OCD. What action should the nurse take first? a. encourage the client to verbalize her feelings b. teach the client relaxation technique c. determine the client's anxiety level d. role-play problem solving behaviors with the clinet

c. determine the client's anxiety level

A nurse is reviewing the lab report of a client who has been taking lithium carbonate for several months. What level should the nurse recognize as a therapeutic lithium level? a. 1.2 b. 1.6 c. 2.0 d. 2.5

a. 1.2

A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as me, see, bee, tree. The nurse recognizes that the client is demonstratting what positive manifestations of schizophrenia? a. clang association b. echolalia c. magical thinking d. word salad

a. clang association

A nurse is caring for a client who has PTSD. What action by the client indicates the current treatment plan is effective? a. client reports techniques she uses to promote sleep b. client shows limited emotion when witnessing a traumatic event c. client asks nurse's opinion about clothes she is wearing d. client avoids situations that might trigger memories of past trauma

a. client reports techniques she uses to promote sleep

A nurse is caring for a client who has OCD. What actions should the nurse take when dealing with the client's ritualistic behaviors? a. plan the client's schedule to allow time to perform rituals b. verbalize disapproval of ritualistic behavior c. place the client in protective isolation d. increase stimuli in client's immediate surroundings

a. plan the client's schedule to allow time to perform rituals

A nurse is assessing a newly admitted client who has generalized anxiety disorder and states, I drink alcohol to forget the pain. The client is exhibiting a maladaptive response to what defense mechanism? a. rationalization b. conversion c. projection d. suppression

a. rationalization

A nurse is caring for a client who has OCD. The client engages in repeated hand washing daily. What should the nurse recognize as the purpose of the client's behavior? a. relieving anxiety b. gaining attention c. avoiding daily responsibilities d. responding to auditory hallucinations

a. relieving anxiety

A nurse on an inpatient unit is assessing a client who has claustrophobia. The nurse determines the client's condition has improved when he can perform what task? a. ride in an elevator b. attend class where several animals are present c. sit in a large room with several people he does not know d. go for a swim in an outdoor pool

a. ride in an elevator

A nurse is caring for a client who has severe anxiety disorder and is in a state of panic in the dayroom. What action should the nurse take? a. speak to the client in a calm voice b. leave the client alone to regain control c. encourage the client to express her feelings d. place the client in restraints

a. speak to the client in a calm voice

A nurse is providing teaching to a cleint who has a new script for alprazolam. What is the priority info the nurse should include in teaching? a. this med can affect yourability to drive or handle mechanical equipment b. you should avoid drinking beverages that contain caffeine with this medication c you should avoid taking antacids within 2 hrs of taking this med d. this med should be taken with/shortly after meals

a. this med can affect yourability to drive or handle mechanical equipment

A nurse in a mental health facility is caring for a client who has generalized anxiety disorder. What statement should the nurse make? a. we'll assist you with making decisions b. someone will work with you when you have flashbacks c. you'll be going through aversion therapy to help you cope d. the therapy will help you control your impulses

a. we'll assist you with making decisions