Mental Health

A client postpartum depression receives prescription for sertraline (Zoloft). What information is most important to include in client teaching? A) Avoid processed meats, red, wine, and Swiss cheese B) Contact the healthcare provider immediately if suicidal thoughts occur. C) Increase activity level to include a daily exercise routine D) Contact the healthcare provider immediately if muscle stiffness

B) Contact the healthcare provider immediately if suicidal thoughts occur.

A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to mental health unit the client is told he has liver damage. Which information is most important for the nurse to include in the client's a discharge plan? A) Eat a high carbohydrate, low fat, low protein diet. B) Do not take any over the counter medication. C) Call the crisis hot line if feeling lonely. D) Avoid exposure to large crowds.

B) Do not take any over the counter medication.

A high school girl reveals to the school nurse that she has been engaging in self-induced vomiting as a weight-control measure. Which initial assessment should the nurse focus on with this adolescent? A) National percentile of weight and height. B) Frequency of bingeing and purging behaviors C) Perceptions of family and social relationships D) School grades and extracurricular activities.

B) Frequency of bingeing and purging behaviors

A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care? A) Implement behaviors modification therapy. B) Indicate caloric and nutritional therapy. C) Evaluate the client for low self- esteem. D) Record daily weights and graft trend.

B) Indicate caloric and nutritional therapy.

The nurse documents the mental status of a female client who has been hospitalized for several days by court order. The client state, "I don't need to be here" and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam? A) Level of concentration B) Insight and judgment C) Remote memory D) Mood and affect

B) Insight and judgment

The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT? A) Hold all bedtime medication. B) Keep the client NPO after midnight. C) Implement elopement precautions. D) Give client an enema at bedtime.

B) Keep the client NPO after midnight.

A client who is admitted to the mental health unit report shortness of breath and dizziness. The client tells the nurse, "I feel like I'm going to die" which nursing problem should the nurse include in this client's plan of care? A) Mood disturbance B) Moderate anxiety C) Altered thoughts D) Social isolation

B) Moderate anxiety

A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide? A) Let's go ask another nurse if this true." B) My name tag shows that I am a nurse here." C) I cannot possibly be one of your children" D) I know that you don't have 9 children"

B) My name tag shows that I am a nurse here."

A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take? A) Report the behavior to the next shift. B) Offer to play a game of cards with the client. C) Document the behavior in the chart. D) Plan to talk with the client the next day.

B) Offer to play a game of cards with the client.

The nurse complete an assessment of a client who is experiencing intimate partner violence (IPV) which finding of the injuries should the nurse include in the documentation? A) The client's significant other's statement B) Photographs C) General description D) A summary of the client's feelings

B) Photographs

After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeterias part of the school's work study program. What action should the nurse take? A) Refer the student to a psychiatrist for further discussion. B) Recommend assignment to the receptionist's office. C) Suggest that the student work in the athletic department. D) Determine the parents' opinion of the work assignment.

B) Recommend assignment to the receptionist's office.

A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which priority nursing problem should the nurse conclude in this client's plan of care? A) Risk for suicide B) Sleep deprivation C) Situational low self-esteem. D) Social isolation.

B) Sleep deprivation

A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 h following admission should the nurse identify as the priority? A) Give lorazepan ( Ativan) PRN for signs of withdrawal B) Administer disulfiram (antabuse) immediately C) Place in side-lying position with head of bed elevated D) Provide thiamine and folate supplements as prescribed

C) Place in side-lying position with head of bed elevated

A male client with a long history of alcohol dependency arrives in the emergency department describing the feeling of bugs crawling on his body. His BP is 170/102. Pulse rate is 110b/min, and his blood alcohol level (BAL)is 0 mg/dl. Which prescription should the nurse administer? A) Haloperidol (Haldol) B) Thiamine (Vit B1) C) Diphenhydramine (Benadryl) D) Lorazepan (Ativan)

D) Lorazepan (Ativan)

A woman brings her 48- years -old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She state that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with: A) Post-traumatic stress syndrome. B) Panic disorder. C) Dissociative disorder. D) Obsessive-compulsive disorder.

C) Dissociative disorder.

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking helpbecause his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool? A) Cancer screening result angerv gastritis daily alcohol intake. B) Consumptiom, liver enzyme gastrointestinal complaints and bleeding C) Efforts to cut down annoyance with question guilt drinking as an eye opener D) Minimizes drinking frequently misses family event guilt about drinking amount of daily intake

C) Efforts to cut down annoyance with question guilt drinking as an eye opener

The nurse orients a female client with depression to her new room on the mental unit. The client state, " It seems strange that I don't have a tv in my room". Which statement would be best for the nurse to provider? A) You can watch TV as much as you want ouside of your room B) Sometime client feel like the TV is sending them messages C) It's important to be out of your room and talking to others D) Watching TV is a passive activity and we want you to be active

C) It's important to be out of your room and talking to others

The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 min to talk with the client. To develop a treatment plan for this client, wich assessment is most important for the nurse to obtain? A) Motivation for treatment B) History of substance use C) Medication compliance D) Mental status examination

D) Mental status examination

The nurse on the day shift receives report about a client with depression who w the weekend. The nurse walks into the client's room in the morning and finds the what intervention is best for the nurse to implement? A) Assist the client to get out bed and involved in an activity. B) Monitor the client's appetite and pattern of sleep. C) Assess the client's feelings about the hospital stay. D) Explain that staff will check on the client every 30 min

A) Assist the client to get out bed and involved in an activity.

patient taking sertraline (zoloft) for postpartum depression, nursing teaching

-contact healthcare provider if having suicidal thoughts (black box warning)

Following surgery, a male client with antisocial personality disorder frequently request that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? A) Reassure the client that his request will be met whenever possible B) Advise the client that assignments are not based on client requests C) Ask the client to explain why he constantly request the nurse D) Encourage the client to verbalize his feelings about the nurse

B) Advise the client that assignments are not based on client requests

A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside , looking for a red one to sit in. when another client objects the disturbance, the client shouts, "I am the boss here. I do what I want" which nursing problem best supports these observation? A) Deficient diversional activity related to excess energy level B) Disturbed personal identity related to grandiosity C) Risk for activity intolerance related to hyperactivity D) Risk for other related violence related to disruptive behaviors

A) Deficient diversional activity related to excess energy level

A male client with bipolar disorder tells the nurse that the needs to " make some deals so that he can improve his retirement savings " based on this information, which client outcome should the nurse include in the plan of care? A) Delay business decisions until his mania subsides. B) Identify the feeling associated with his behaviors C) Seek legal counsel when making business decisions D) Describe why he is feeling fearful about his finances.

A) Delay business decisions until his mania subsides.

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A) Excessive CNS stimulation will be reduce B) Co- dependent behaviors will be decreased C) Client's level of consciousness will increase. D) Client will not demonstrate cross- addiction

A) Excessive CNS stimulation will be reduce

A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply) A) Have a bag ready that has extra clothes for self and children. B) Establish a code with family and friend to signify violence. C) Purchase a gun to use for protection D) Take a self-defense course that retaliate the abuser with injury. E) Plan an escape route to use if the abuser blocks the main exit.

A) Have a bag ready that has extra clothes for self and children. B) Establish a code with family and friend to signify violence. E) Plan an escape route to use if the abuser blocks the main exit.

A male client comes to the emergency center he has an erection that will no resolve the client reports that he is taking trazodone (desyrel) for insomnia which information is most important for the nurse to ask this client? A) Have you taken any medication for erectile dysfunction?" B) Are you having any other sexual dysfunctions or problems?" C) When was the last time you drank an alcoholic beverage?" D) Do you have a history of angina or high BP?"

A) Have you taken any medication for erectile dysfunction?"

Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? A) I am here because the police thought I was doing something wrong" B) I want to be here because I know it is the best psychiatric facility" C) At least I hit the wall instead of hitting the psychiatric aide" D) Don't believe everything my family tells you, I am not crazy"

A) I am here because the police thought I was doing something wrong"

A mental health worker (MHW) is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the nurse? A) Is attempting to physically restrain the client. B) Tells the client to go to the quiet area of the unit. C) Is using a loud voice to talk to the client. D) Remains at a distance of 4 feet from the client.

A) Is attempting to physically restrain the client.

A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What A) Offer the client a safe place to relax before interviewing her. B) Ask the client to describe why she is being stalked. C) Recommend that the client talk with a social worked. D) Assure client that the healthcare provider will see her today.

A) Offer the client a safe place to relax before interviewing her.

The nurse is completing the admission assessment of and underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider? A) Potassium level 2,9 mEq/dl B) BP of 110/70 mm/hg C) WBC of 10,000 mm3 D) Body mass index of 21

A) Potassium level 2,9 mEq/dl

A client who refuse antipsychotic medications disrupts group activities, talks with nonsensical words wanders into client's room. The nurse decides that the client needs constant observation based on which of these assessment findings? A) Wanders into client's rooms. B) Refuse antipsychotic medication. C) Talks with nonsensical words. D) Disrupts group activities.

A) Wanders into client's rooms.

A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? A. Stay quietly with the patient B. Tell her that she is out of control. C. Distract her by offering her finger foods. D. Ignore the client's acting out behavior.

A. Stay quietly with the patient

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic the client tells the nurse that he usually takes a different dosage. What action should the nurse take? A) Tell him to take the medication then verify the dosage at the next healthcare team meeting B) Withhold the medication until the dosage can be confirmed C) Inform him that he may refuse the medication and document whether or not he take it D) Explain to the client that the dosage has been changed

B) Withhold the medication until the dosage can be confirmed

Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview? A. Client's medication history includes the frequent use of antidepressants. B. Describe self as a social drinker who drinks alcoholic beverages daily. C. Reports difficulties with short term memory since traumatic brain injury. D. Medical history includes that the client was recently sexually assaulted.

B. Describe self as a social drinker who drinks alcoholic beverages daily.

A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? A. Decreased bowel movements. B. Presence of a dry mouth. C. Decreasing hand tremors. D. Increased mouth movements.

B. Presence of a dry mouth.

A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A) Transport of the client to the seclusion room B) Quietly approach the client with additional staff members. C) Take other client in the area to the client lounge. D) Administer medication to chemically restrain the client

C) Take other client in the area to the client lounge.

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A) Encourage the client to exercise B) Suggest that the client to develop a list of pleasurable activities C) Teach the client to develop a plan for daily structured activities D) Provide education on methods to enhance sleep

C) Teach the client to develop a plan for daily structured activities

A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee's history is most related to the reaction that occurred? A) Is worried about losing his job to a woman B) Tortured animals as a child. C) Was physically abused by his mother D) Hates to be touched by anyone

C) Was physically abused by his mother

Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (vicodin). Within 15 min the client is alert and oriented. In planning nursing care which intervention has the highest priority at this time? A) Encourage the client to increase fluid intake. B) Obtain the client's serum vicodin level C) observe the client for further narcotic effects D) determine the client's reason for attempting suicide

C) observe the client for further narcotic effects

A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the RN take? A. Encourage the client to stay in the hospital so the client does not have to be homeless. B. Provide the client with medication if the client presents an imminent risk to self and others. C. Administer a long acting antipsychotic medication so that the client can be discharged to a shelter. D. Describe to the client treatment options provided at the community mental health clinics.

C. Administer a long acting antipsychotic medication so that the client can be discharged to a shelter.

The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement? A. Monitor the client's appetite and pattern of sleep. B. Assess the client's feelings about the hospital stay. C. Assist the client to get out of bed and involved in an activity. D. Explain that staff will check on the client every 30 minutes.

C. Assist the client to get out of bed and involved in an activity.

The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction? A. Benzodiazepine B. Alcohol C. Methamphetamine D. Marijuana

C. Methamphetamine

A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just wanted to go sleep" the nurse should plan one-on- one observation of the client based on which statement? A) What should I do? Nothing seems to help." B) I have been so tired lately and needed to sleep." C) I really think that I don't need to be here." D) I don't want to talk. Nothing matters anymore."

D) I don't want to talk. Nothing matters anymore."

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confuse. The nurse also determines that the client is homeless and slightly suspicious. This client's treatment plan should include what priority problem? A) Self-care deficit. B) Disturbed sensory perception. C) Ineffective community coping. D) Acute confuse.

D) Acute confuse.

The nurse is planning client teaching for a 35 year old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client's recovery? A) Support group meetings B) Vit B and multivitamin supplement C) Diet with adequate calories and protein D) Alcohol abstinence

D) Alcohol abstinence

A client who is known to abuse drugs is admitted to the psychiatric unit. With medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? A) Diphenhydramine (Benadryl) B) Perphenazine (trilafon) C) Isocarboxazid (marplan) D) Clordiazepoxide (Librium)

D) Clordiazepoxide (Librium)

A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting and drowsiness. What action should the nurse take? A) Notify de healthcare provider immediately and prepare for admon of an antidote B) Hold the medication and refuse to admon additional amounts of the drug C) Record the symptoms as normal side effects and continues admon of the prescribed dosage D) Notify the health care provider of the symptoms prior to the next admon of the drug

D) Notify the health care provider of the symptoms prior to the next admon of the drug

A female client engages in repeated checks of door and a window lock behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? A) Ask the client why she checks the locks B) Discuss checking the time frequently C) Determine the type and size of the locks D) Plan a list of activities to be carried out daily

D) Plan a list of activities to be carried out daily

The nurse leading a group session of adolescent client gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take? A) Explore the client's feelings about his pet and home life. B) Encourage his peers to help involve him in the activity. C) Give the client permission to leave and return in 10 min. D) Redirect him by encouraging him to read from the handout.

D) Redirect him by encouraging him to read from the handout.

While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-take during an interview? A) The client's comfort level is increased when the nurse breaks eye contact to take notes. B) The interview process is enhanced with note taking and allows the client's to speak at a normal pace. C) Taken note during an interview is a legal obligation of the examining nurse. D) The nurse's ability to directly observe the client's nonverbal communication is limited with note taking.

D) The nurse's ability to directly observe the client's nonverbal communication is limited with note taking.

A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client's behavior? A. Ineffective protection to guard self from internal or external threats. B. Risk for injury related to inability to communicate. C. Risk prone health behavior related to self-esteem assault. D. Anxiety related to real or perceived threat to physical integrity.

D. Anxiety related to real or perceived threat to physical integrity.

On admission to the mental health unit, a client diagnosed with schizophrenia tells the RN that he is the son of god. Based on this statement, which intervention should the RN include in this client's plan of care? A. Lead the client by his arm to the seclusion room. B. Ensure the client's environment is safe. C. Schedule activity therapy twice a week. D. Confront his delusion as not consistent with reality.

D. Confront his delusion as not consistent with reality.

A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? A. Visual hallucinations. B. Auditory hallucinations. C. Excessive motor activity. D. Delusions of persecution.

D. Delusions of persecution.

While caring for an older client, the RN observes multiple bruises in Over the client's legs, arms, back, and gluteal areas. When the client Contact, the RN suspects elder abuse. What action should the RN take? A. Report family conversations and anger towards the client when visiting. B. Ask the client specific questions about someone causing the bruising. C. Question the family members and caregiver how the bruising occurred. D. Measure and document size, shape and color of the bruised areas.

D. Measure and document size, shape and color of the bruised areas.

After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school's work study program. What action should the RN take? A. Suggest that the student work in the athletic department. B. Determine the parent's opinion of the work assignments. C. Refer the student to a psychiatrist for further discussion. D. Recommend assignment to the receptionist's office.

D. Recommend assignment to the receptionist's office.

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review? a. Abnormal Involuntary Movement Scale (AIMS) b. Recent urine drug testing (UDT) results. c. Baseline nursing admission assessment. d. The healthcare provider's history and physical.

a. Abnormal Involuntary Movement Scale (AIMS)

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client's history should the nurse further explore? a. Alcohol use b. Witness to an accident c. Family history of dementia d. In adequate diversional activity

a. Alcohol use

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors is most important for the nurse to monitor? a. Argumentativeness and use of profanity b. Periodic sighing and shaking the head c. Repeated requests for attention from the nurse d. Decreased activity level and change in affect

a. Argumentativeness and use of profanity

The nurse is teaching a group of adolescents about assertiveness communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement? a. Ask the adolescent sitting on the couch to join the group at the table b. Allow the adolescents to sit wherever they wish as long they participate c. Determine which adolescents would like to participate in the discussion d. Suggest that they all sit together to increase the interaction.

a. Ask the adolescent sitting on the couch to join the group at the table

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during for the first 24 hours after admission? a. Assess intake and output b. Limit visitors to family members only c. Monitor for wheezing and apnea d. Assign the client to a teen support group

c. Monitor for wheezing and apnea

Which is the best approach for the nurse to use when interviewing a client about suicidal ideations? a. Begin with questions that are less sensitive in nature b. Get the most difficult questions over with first c. Ask questions in a vague, non-specific format d. Share personal values to put the client at ease

a. Begin with questions that are less sensitive in nature

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalated, and the client becomes physically aggressive. Which intervention should the nurse implement first? a. Confirm the client's identity and orientation to time and place b. Request a team member to assist with seclusion with restraint c. Inspect the area for objects that can be used in a dangerous manner d. Administer lorazepam 1.5 mg intramuscularly twice daily as needed

a. Confirm the client's identity and orientation to time and place

A client with a history of opioid dependence presence to the emergency department unresponsive with bradypnea and pinpoint pupils. Which intervention should the nurse implement first. a. Establish a patent airway b. Obtain vascular access with large bore catheter c. Perform a Glasgow Coma Scale (GCS) assessment d. Determine blood pressure and pulse

a. Establish a patent airway

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? a. Ineffective breathing pattern b. Risk for injury c. Ineffective coping d. Impaired comfort

a. Ineffective breathing pattern

A male client tells the nurse that he has an IQ of 400 + and is genius and an inventor. He also reports and he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit? a. Ineffective sexual patterns b. Disturbed sensory perception c. Impaired environmental interpretation d. Compromised family coping.

a. Ineffective sexual patterns

Two days after being admitted with alcohol withdrawal, a client has constant liquid stools and abdominal cramping. The emesis and stool are hemoccult positive. The client is confused and refusing to take oral medication. Which action should the nurse implement first? a. Insert peripheral intravenous catheter b. Administer an anti-anxiolytic medication c. Insert fecal management tube d. Crush pills and place in applesauce

a. Insert peripheral intravenous catheter

A client with bipolar disorder has not slept or eaten in four days, The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time? a. Move to a quiet area and provide peanut butter with crackers. b. Encourage the souse to eat lunch with the client c. Walk with the client to the cafeteria and stay while client eats. d. Request a full lunch tray from the dietary department.

a. Move to a quiet area and provide peanut butter with crackers.

After several days of being respondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement? a. Observe her actions continuously b. Praise her for the new behavior c. Involve her in group therapy d. Offer her a choice of activities

a. Observe her actions continuously

A female client request that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take? a. Pay close attention and document the nonverbal messages b. Ask the client's husband to interpret the discrepancy c. Ignore the nonverbal behavior and focus on the client's verbal messages. d. Integrate the verbal and nonverbal messages and interpret them as one.

a. Pay close attention and document the nonverbal messages

A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement? a. Report the client's serum lithium level to the healthcare provider b. Encourage the client to suck on hard candy to relieve the symptoms c. No actions is needed since polydipsia is a common side effect d. Tell the client that drinking from the faucet is not allowed

a. Report the client's serum lithium level to the healthcare provider

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client? a. Tell the client that confidentially will be maintained, except when one's safety is threatened b. Provide the client with a written hospital policy regarding privacy of information laws c. Nod in the affirmative, but make no verbal commitment to the client d. Assure the client that information provided will be shred with the staff only

a. Tell the client that confidentially will be maintained, except when one's safety is threatened

A client who was in a motor vehicle collision related alcohol intoxication is recovering in the hospital following surgery. Which statement by the client's spouse indicates codependency? a. The spouse informs the client of plans to move out of their home if the drinking doesn't stop. b. The spouse tells the nurse the accident was precipitated by high stress that led to drinking c. The spouse tells the nurse that the client was irresponsible and reckless for driving while drunk. d. The spouse tells the client they were attending a wedding of friends the following day

a. The spouse informs the client of plans to move out of their home if the drinking doesn't stop.

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings? a. Wanders into client's rooms b. Refuses antipsychotic medications c. Disrupts group activities d. Talks with nonsensical words

a. Wanders into client's rooms

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time? a. Complete a thorough room search to ensure client does not have access to objects that can be used for self-harm b. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk self-mutilation c. Give client firm, consistent expectation that self-mutilating behaviors are unacceptable and will not be allowed d. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation

b. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk self-mutilation

Which individual should the nurse consider at highest risk for suicide? a. A single working mother with three pre-school aged children b. A retired older male whose significant other passed away c. An adolescent male whole parents recently divorced d. A nurse who works in a pediatric emergency department

b. A retired older male whose significant other passed away

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued? a. Lithium (lithotabs ) b. Benztropine (Cogentin) c. Alprazolam (Xanax) d. Magnesium (milk of magnesia)

b. Benztropine (Cogentin)

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client's tongue is "worming". The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain? a. Unusual level of activity and average sleep pattern b. Dentures to determine if they are poorly fitted c. Body weight over the past three months d. Blood pressure when sitting and standing

b. Dentures to determine if they are poorly fitted

The nurse determines that a client has been taking antidepressants for the past six months. Which symptoms are common side effects of this classification of drugs? a. Insomnia, hypertension, and vomiting b. Dry mouth, blurred vision, and constipation c. Bradycardia, delirium, and sedation d. Headache, jaundice, and diarrhea

b. Dry mouth, blurred vision, and constipation

A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in this client's plan of care. a. Encourage the client to interact with persons who are recovering from depression b. Encourage activities that allow the client to exert control over his environment c. Avoid discussing subjects that upset the client d. Allow the client time alone to sort out his feelings

b. Encourage activities that allow the client to exert control over his environment

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? a. Encourage substitution of positive thoughts for negative ones b. Establish trust by providing a calm, safe environment c. Progressively expose the client to larger crowds d. Encourage deep breathing when anxiety escalates in a crowd

b. Establish trust by providing a calm, safe environment

A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take? a. Notify the physician immediately and force fluids. b. Prior to giving the next dose, notify the physician of the symptoms. c. Record the symptoms and continue medication as prescribed. d. Hold the medication and refuse to administer additional amounts of the drug.

b. Prior to giving the next dose, notify the physician of the symptoms.

A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" the nurse recognizes that the client is using which defense mechanism? a. Denial b. Projection c. Rationalization d. Splitting

b. Projection

The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? a. Completely abstain from heroin or cocaine use b. Remain alcohol free from 12 hours prior to the first dose c. Attend monthly meetings of alcoholics anonymous d. Admit to others that he is a substance abuser

b. Remain alcohol free from 12 hours prior to the first dose

A young adult female client is admitted to the Emergency Department after being raped in a shopping center parking lot. The client expresses no suicidal ideation but expresses feelings of self-blame for not taking precautions when going to her car. According to theorists, such as Maslow and Erickson, this client is struggling with which issue? a. Self-control b. Self-actualization c. Self-esteem d. Self-absorption

b. Self-actualization

A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement? a. Ask the client to repeat his comments b. Teach the client to slow down and focus on the topic by listening to his words c. Confront the client when he talks rapidly d. Tell the client to discuss his ideas with others when his thoughts are more clear.

b. Teach the client to slow down and focus on the topic by listening to his words

During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take? a. Share similar experiences the nurse has had in the past b. Terminate the session before the feelings escalate c. Resolve the feelings with the client after discharge d. Identify the client's transference of feelings annoyance

b. Terminate the session before the feelings escalate

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? a. Appetite b. The emotional quality of attitude c. The interactions with others d. Level of activity

b. The emotional quality of attitude

Two weeks after a tornado hit a small town, a young woman whose was destroyed comes to the crisis center for assistance. The client tells the nurse, that though her home was destroyed, none of her family was hurt. She further states, "You don't know what it was like, and now I am having to live with relatives." Which response is best for the nurse to provide? a. Tell me about your experience with this disaster b. What are you doing to cope with these changes? c. How did you and your family survive the tornado? d. Disaster relief funds can assist you with housing.

b. What are you doing to cope with these changes?

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take? a. Determine if the client is taking an anticholinergic drug such as benztropine mesylate b. Call the healthcare provider and refuse to administer any more chlorpromazine c. Decrease the dose of chlorpromazine and notify the healthcare provider d. This is an expected side effect of chlorpromazine which requires no further action

c. Decrease the dose of chlorpromazine and notify the healthcare provider

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in plan of care? a. Takes all antianxiety medications as prescribed b. Participates in individual and group therapy c. Demonstrates effective ways to cope with anxiety d. Learns methods of relaxation to reduce anxiety

c. Demonstrates effective ways to cope with anxiety

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder? a. An adolescent who becomes extremely anxious about going outside b. An older adult who continuously complains of a headache and back pain c. A young woman who suddenly goes blind with no indication of organic pathology d. A missile-aged man who is complaining a shortness of breath and is diaphoretic

c. A young woman who suddenly goes blind with no indication of organic pathology

A female client with obsessive-compulsive personality disorder is admitted to the hospital for a catheterization. The afternoon before a procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the nurse at bedtime. What action should the nurse implement? a. Explain to the client that her behavior invades the rights to the nursing staff b. Ask the client to explain why she is keeping a detailed record of her nursing care c. Encourage the client to express her feelings regarding the upcoming procedure. d. Teach the client strategies to control her obsessive-compulsive behavior

c. Encourage the client to express her feelings regarding the upcoming procedure.

Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all the above) a. Limit time allowed to play video games b. Restrict visitors to family members only c. Encourage the clients to discuss thoughts and feelings about wanting to die d. Reinforce statements regarding a will to live and realistic plans for the future e. Discuss the client's suicide plan

c. Encourage the clients to discuss thoughts and feelings about wanting to die d. Reinforce statements regarding a will to live and realistic plans for the future

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? a. Client will not demonstrate cross addiction. b. Co-dependent behaviors will be decreased. c. Excessive CNS stimulation will be reduced. d. Client's level of consciousness will increase.

c. Excessive CNS stimulation will be reduced.

A client with paranoia is admitted to the mental health unit and immediately does to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first? a. Read the client his/her rights b. Show the client the unit c. Explain the nurse's role to the client d. Offer medication to the client

c. Explain the nurse's role to the client

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care? a. Relax and reduce the amount of effort to solve the problem b. Shift attention from self to the needs and requests of others c. Focus on small achievable tasks, not taxing problems d. Concentrate on and ventilate emotions when distressed

c. Focus on small achievable tasks, not taxing problems

The mental health nurse observes that female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust? a. Explain that these beliefs are related to her illness b. Explain that distrust is related to feeling anxious c. Initiate short, frequent contacts with the client d. Offer to keep the belongings at the nurse's desk

c. Initiate short, frequent contacts with the client

A client with a mood disorder receives a new prescription for lithium carbonate. Which information provides by the client requires additional instruction by the nurse? a. Therapeutic effects may take 3 weeks b. Blood will be drawn routinely c. Insomnia is a common side effect d. Gastric upset may be experienced

c. Insomnia is a common side effect

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands od people. Which actions should the nurse take? a. Immediately inform the provider that the client is experiencing a delusional episode. b. Attempt to comfort the client by agreeing with the delusions and ask open ended questions c. Present a personal perception of reality in a non-confrontational manner d. Disagree with the statement and set clear limits on talking about it

c. Present a personal perception of reality in a non-confrontational manner

A client with depression remains in bed most of the day, declines activities and refuses meals. Which nursing problem has the greatest priority for this client? a. Loss of interest in diversional activity. b. Social isolation c. Refusal to address nutritional needs d. Low self-esteem.

c. Refusal to address nutritional needs

A female client with obsessive compulsive disorder complains that she feels "driven" to check the locks on her front door at least six times every night. Which response is best for the nurse to provide? a. What are your thoughts when you are checking the locks? b. Feelings of being driven to do something are related to anxiety c. Repeating the same behavior helps you to diminish your anxiety d. Have you had a bad experience related to unlocked doors?

c. Repeating the same behavior helps you to diminish your anxiety

An adult client presents to the community mental health center accompanied by the client's spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last minute decisions to take trips, sleeps only 2 to 4 hours a night, and had lost 33 pounds (15kg) in the last 2 months. Which nursing problem has the greatest nursing priority? a. Imbalanced nutrition related to caloric expenditure b. Sleep deprivation related to state of hyperactivity c. Risk for self-directed violence related to impulsive behavior d. Ineffective coping related to biochemical changes

c. Risk for self-directed violence related to impulsive behavior

Which reasons should the nurse expect a female client to use when she is having difficulty leaving a relationship where she is a victim of intimate partner violence? (SATA) a. Religious beliefs about marriage b. The perpetrator will not change c. Shame or guilt d. Children e. Financial dependency

c. Shame or guilt e. Financial dependency

A male client, assessed in the emergency department (ED), has a strong odor of an alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, "Now I'm going to shoot myself." a. Inquire about the client's support system b. Record the statement in the client's chart c. Stop the client from leaving the ED d. Ask the client to repeat his comment

c. Stop the client from leaving the ED

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client? a. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol. b. Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication c. Take the medication each morning beginning 48 hours after your last drink of alcohol d. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily.

c. Take the medication each morning beginning 48 hours after your last drink of alcohol

An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement? a. Reinforce the need for the adolescent to attend group therapy sessions. b. Refer the mother for psychiatric evaluation for anxiety and depression c. Tell the mother to describe her feelings for helplessness to her son d. Advise the mother to call the police if violent behavior occurs again.

c. Tell the mother to describe her feelings for helplessness to her son

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement? a. Nutrition referral b. Individual addiction counseling c. Thiamine administration d. Initiate disulfiram teaching

c. Thiamine administration

n older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement. a. Assist the client in developing an emergency safety plan b. Tell the client to call Adult Protective Services if his son's abuse continues c. Verify the client's report by determining if there is physical evidence of abuse d. Refer the client to a program for victims of domestic violence.

c. Verify the client's report by determining if there is physical evidence of abuse

CAGE TOOL assessment

cut down on your drinking, people annoyed you, felt bad or guilty about your drinking, drink first thing in the morning hangover (Eye-opener)

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a literally contracted position, he states that something has made his body confort into a monster. What action should the nurse take? a) Medicate the client with the prescribed antipsychotic thioridazine (mellaril) b) Offer the client a prescribed physical therapy hot pack for muscle spasms. c) Direct client to occupational therapy to distract him from somatic complaints. d) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

d) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client's husband recently lost his job, she feels her employment is essential to the family survival. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcome should the nurse include in the plan of care? a. Relates insight into problematic relationships b. Demonstrates a healthy relationship with husband c. Describe how the family can be resolve problems d. Changes thought patterns related to problem solving

d. Changes thought patterns related to problem solving

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client a. Have you lost interest in the things that you used to enjoy? b. Is your ability to think or concentrate decreased? c. How many continuous hours do you sleep at night d. Do you hear sounds or voices that others do not hear?

d. Do you hear sounds or voices that others do not hear?

A female client with obsessive compulsive A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement? a. Explain to the client that her behavior invades the rights of the nursing staff. b. Ask the client to explain why she is keeping a detailed record of her nursing care. c. Teach the client strategies to control her obsessive compulsive behavior. d. Encourage the client to express her feelings regarding the upcoming procedure.

d. Encourage the client to express her feelings regarding the upcoming procedure.

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client's plan of care. a. Enforcing a fluid restriction during dosage adjustment b. Shielding the client from direct sunlight when outdoors. c. Increasing the dosage if the while blood cell count drops d. Gradually with drawing the medication over several days.

d. Gradually with drawing the medication over several days.

The nurse is taking the history of an young adult female who is 5 feet 3 inches (160 cm) tall and weighs 90 pounds (40.9kg). Which reported finding is most important for the nurse to address immediately? a. Absence of menstrual cycle b. Severe constipation c. Seen walking fast outdoors d. Intermittent palpitations

d. Intermittent palpitations

During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains the he often gets so angry while driving to and from work that he has considered "getting even" with other drivers, how should the nurse respond? a. "anger is contagious and could result in major confrontation" b. "Try not to let your anger cause you to act impulsively" c. "expressing your anger to a stranger could result in an unsafe" d. It sound as if there are many situations that make you feel angry"

d. It sound as if there are many situations that make you feel angry"

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first? a. Escort the client to his room b. Administer a PRN sedative c. Sit in the chair next to the client d. Listen to what the client is saying

d. Listen to what the client is saying

A male client a long history of alcohol dependency arrives in the Emergency Department describing the feeling of bugs crawling on his body. His pressure is 170/102 mmHg, pulse rate is 110 beats/minute, and blood alcohol level (BAL) is 0mg/dL. Which prescription should the nurse administer? a. Diphenyhydramine b. Thiamine c. Haloperidol d. Lorazepam

d. Lorazepam

Prior to initiating a treatment regimen with the antidepressant sertraline. It is most important for the nurse to obtain which information? a. Familial history of mental illness b. Current weight c. Any history of heart disease. d. Medication history

d. Medication history

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client's plan of care? a. Place the client in protective isolation for the first two weeks of treatment with this medication b. Offer this medication to the client with food to decrease the possibility of gastric upset c. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever d. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider

d. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition? a. Preoccupation b. Disorganization c. Reexperience d. Somatization

d. Somatization

A client who is experiencing a severe level of anxiety and reports a caring heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take? a. Help the client to identify thoughts that may triggers b. Explore past behaviors that have provided relief c. Attempt to distract to another focus or activity d. Speak calmly to the client stating assurance of safety

d. Speak calmly to the client stating assurance of safety

When the nurse addresses questions to an adult female client who is depressed, the client's responded are delayed. Which intervention should the nurse include in this client's plan of care? a. Observe for signs of possible psychosis b. Involve client in daily exercise program c. Ask the client to describe her depression d. Spend time sitting in silence with client.

d. Spend time sitting in silence with client.

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse report? a. Advise the client to reschedule until committing to recovery b. Provide teaching on the symptoms of substance use dependence. c. Explain the specific the skills needed to prevent a relapse d. Support the client to list small behavioral changes needed

d. Support the client to list small behavioral changes needed