Mental Health Passpoint CH 1

A nurse is conducting a group session for parents of toddlers recently diagnosed with autism. Which parent statement indicates a need for additional teaching?

"Children with autism may be overwhelmed by rules and structure." Explanation: Children with autism spectrum disorder tend to function best with clear rules, routine and daily structure. Children with autism may develop normally until 18 to 24 months old at which time their development may be stifled or they may regress. Many people with autism have difficulty with muscle tone and coordination, which can affect their ability to reach developmental milestones. Children with autism often have sensory dysfunction and are extremely sensitive to sounds, smells, textures, and tastes.

The nurse is performing an admission interview when the client attempts to shift the session focus to the nurse by asking personal questions. Which statement by the nurse is most appropriate?

"I have a family. Tell me about you and your family." Explanation: The nurse's self-disclosure should be brief, vague, and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, discussion should not dwell on the nurse's experience. Telling the client that the nurse should control the conversation or not give personal information could be considered argumentative.

Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder?

"I understand my pain will feel worse when I am worried about my divorce." Explanation: The client who states, "I understand my pain will feel worse when I am worried about my divorce" recognizes the connection between his pain and the divorce and indicates developing insight into his problem. The nurse should then be able to assist the client with developing adaptive coping strategies. The other statements indicate a lack of insight into his disorder and lack of progress toward recovery. The client is still searching for the "right" diagnosis, medication, and health care provider (HCP).

The client has been instructed in anger management. Which statement would indicate understanding of introjection?

"I will react to anger like I have seen my parents react." Explanation: Introjection is (assuming as one's own) one's parents' belief that anger shouldn't be outwardly expressed. Displacement is the discharge of negative feelings onto another person or an object. Projection is the attribution of one's own thoughts or impulses to another person. Sublimation is the channeling of unbearable or socially unacceptable behaviors into more socially acceptable outlets.

The nurse is educating a client on the first dose of venlafaxine. Which statement(s) by the client indicates further teaching is necessary? Select all that apply.

"I will start to feel better immediately after taking my medication in the morning." "Agitation and restlessness are common after taking the first dose." "If I have a lot of side effects, I can immediately stop taking this medication." Explanation: Venlafaxine is a selective serotonin and norepinephrine reuptake inhibitor used for depression and anxiety disorders. This medication takes approximately 2 weeks to be effective; therefore, the client will not see immediate results. Feelings of agitation and restlessness after the first dose of venlafaxine can be a sign of serotonin syndrome, which can be life-threatening and requires follow up. Suicidal thoughts and thoughts of self-harm, especially early in therapy, should be addressed immediately. Drowsiness is a common side effect seen with venlafaxine and can be helped with afternoon naps. Clients should not stop venlafaxine suddenly as this can cause serotonin withdrawal. If this medication needs to be discontinued, the client should be educated on reducing the dose gradually and watching for serotonin withdrawal symptoms.

A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?

"When my moods fluctuate, I'll increase my dose of lithium." Explanation: A client who states that mood fluctuation warrants increasing the dose of lithium requires additional teaching. Increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.

The nurse meets with a client in the outpatient clinic who is suicidal and refuses participate in creating a suicide safety plan. What should the nurse do next?

Arrange for immediate hospitalization on a locked unit. Explanation: A suicide safety plan is a written set of instructions to follow if a client begins to have self-harm thoughts. Plans are written by the client and care team when the risk for suicide is not considered high enough to warrant hospitalization. The nurse should arrange for immediate hospitalization on a psychiatric intensive care unit when the suicidal client refuses to help develop a safety plan. A psychiatric intensive care unit or locked unit is the appropriate setting and least restrictive environment to provide safety for a high-risk client. When clients are treated in an outpatient area, procedures must be in place for swift admission to an inpatient area that has a locked unit. The group home, a partial program, or a subacute unit would not provide the maximum safety that the client needs.

A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child?

Define behaviors that are acceptable and behaviors that are not permitted. Explanation: Children need to know what behaviors are acceptable and what behaviors are unacceptable. They feel more secure when limits are clear and when policies concerning their behavior are consistently enforced.Increasing sensory stimulation tends to increase hyperactive and impulsive behavior.Limiting opportunities to verbalize anger and frustration tends to increase stress and frustration for the child.Physical activities are needed to help the child expend energy, reduce anxiety, and increase self-worth.

The nurse notes that a client sitting in a chair has not gotten up in 1 hour. The client does not respond to verbal directions, and her arm has been extended over the armrest for 30 minutes. What should the nurse do next?

Give PRN-prescribed doses of haloperidol and lorazepam. Explanation: The client is exhibiting catatonic behavior, an acutely serious result of severe anxiety and psychosis. In this situation, the nurse needs to administer the PRN-prescribed doses of haloperidol and lorazepam; they can be given together safely. Assisting the client out of the chair to go back to bed or sitting quietly until the client responds ignores the seriousness of the client's condition. It is unlikely that the client can describe what is being experienced.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

Obtain the sliding board or two other people to assist us." Explanation: To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available, the nurse should use the sliding board. The hydraulic lift isn't the appropriate equipment to use with a sedated patient. The nurse shouldn't place the client in a semi-Fowler's position unless there is a head injury or other complicated medical condition. To perform a safe transfer using a drawsheet, the nurse must place the sheet directly under the client's body.

When a client is about to lose control, the extra staff who come to help commonly stay at a distance from the client unless asked to move closer by the nurse who is talking to the client. What statement best explains the primary rationale for staying at a distance initially?

The client is likely to perceive others as being closer than they are and feel threatened. Explanation: The client who is about to lose control is experiencing a high degree of anxiety or agitation, which alters the client's ability to perceive reality. Initially, the client may feel threatened by the presence of others. A client who is out of control is not thinking about having an audience. Although the nurse with the client who is about to lose control is generally the one giving directions, this is not a rationale for staying at a distance. When seeing extra staff, the client may or may not be able to gain self-control.

A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially?

The most appropriate initial outcome for the client is to discuss thoughts and feelings related to her losses. The nurse should help the client identify and verbalize her feelings so that she can externalize her thoughts and emotions and begin to deal with them. This prevents the client from internalizing feelings, which leads to depression and self-harm. The ability to identify two positive qualities, explore strengths, and prioritize problems would be appropriate after the client has explored her thoughts and feelings, gained awareness of the issues, and then can participate in the treatment plan.

A client becomes angry and belligerent toward the nurse after speaking on the phone with the client's mother. The nurse recognizes this as what defense mechanism?

displacement Explanation: Displacement is a defense mechanism in which the client transfers feelings for one person to another person who is less threatening. Rationalization is a defense mechanism in which the client makes excuses to justify unacceptable feelings or behaviors. Repression is characterized by an involuntary blocking of unpleasant experiences from one's consciousness. Suppression is the conscious blocking of unpleasant experiences from one's awareness.

The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older adult clients?

fears and conflicts about aging Explanation: The most common reason for a nurse's discomfort with older adult clients is that the nurse has not conducted a self-examination of fears and conflicts about aging. Until nurses resolve their fears, it is unlikely that they will feel comfortable with older adult clients. A dislike of physical contact with older people, a desire to be surrounded by beauty and youth, and recent experiences with a parent's older adult friends are possible explanations, but not common or likely.

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called:

flight of ideas. Explanation: Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the next with some connection. Looseness of association describes a pattern in which ideas lack an apparent logical connection to one another. Tangential thoughts seem to be related but miss the point. A client who talks around a subject and includes a lot of unnecessary information is exhibiting circumstantial thinking.

When planning the care for a client who is being abused, which measure is most important to include?

helping the client develop a safety plan Explanation: The client's safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care. Being empathetic, teaching about abuse, and explaining the person's rights are also important after safety is ensured.

The nurse correctly judges that the danger of a suicide attempt is greatest with which client behavior?

increase in energy level Explanation: The client's energy level is related to the danger involved. Suicide attempts are more likely carried out when the client has more energy to act on thoughts and impulses. A client may not have the energy to commit suicide during times of severe depression.Resuming a former lifestyle is usually a sign of improvement unless the lifestyle places the client in danger.Visiting an estranged sibling does not indicate that a suicide attempt is imminent.

A client with a chronic mental illness who does not always take her medications is separated from her husband and receives public assistance funds. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and also receives public assistance benefits. The client's sister works outside the home, and the client's father is dead. Which issue should the nurse address first?

medication compliance Explanation: Medication noncompliance is a primary cause of exacerbation in chronic mental illnesses. Of the issues listed, medications should be addressed first. Other issues, such as family, marriage, and finances, can be addressed as client stabilization is maintained.

A nurse is teaching the families of clients with chronic mental illnesses about causes of relapse and rehospitalization. What should the nurse include as the primary cause?

noncompliance with medications Explanation: Noncompliance with medications is documented as the primary cause of relapse. Although loss of family support, sudden changes in medications, and nonattendance at treatment programs may contribute to relapse, these factors are not as significant as medication noncompliance as causes of relapse.

A nurse is developing a care plan for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention?

reorienting the client to time and place Explanation: Confusion and temporary memory loss are the most common adverse effects of ECT. A nurse should continually reorient a client to time and place as the client wakes up from the procedure. Following ECT, the nurse should monitor the client's vital signs every 15 minutes for the first hour. The nurse should position the client on the side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until fully awake and oriented.

Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness?

repression Explanation: Repression, the unconscious exclusion from awareness of painful or conflicting thoughts, impulses, or memories, is the primary ego defense. Other defense mechanisms tend to reinforce anxiety. Introjection is an intense identification in which one incorporates values or qualities of another person or group into one's own ego structure. Regression is a retreat, during a time of stress, to an earlier level of developmental behavioral. Denial is avoiding unpleasant realities by ignoring them.

A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families?

role stereotyping Explanation: The traditional and rigid gender roles described by the client are examples of role stereotyping. Impermeable boundaries, unbalanced power ratio, and dysfunctional feeling tone are also common in abusive families.

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

tachycardia, weight loss, and mood swings Explanation: Stimulants produce mood swings, anorexia and weight loss, and tachycardia. Hyperpyrexia, slow pulse, weight gain, hypotension, listlessness, increased appetite, slowing of sensorium, and arrhythmias indicate CNS depression.

When assessing a client for suicidal risk, which method of suicide should the nurse identify as most lethal?

use of a gun to the stomach Explanation: A crucial factor in determining the lethality of a method is the amount of time that occurs between initiating the method and the delivery of the lethal impact of the method. Lethal methods of suicide include using a gun, jumping from a high place, hanging, drowning, carbon monoxide poisoning, and overdose with certain drugs, such as central nervous system depressants, alcohol, and barbiturates. The more detailed the suicide plan, the more lethal and accessible the method, and the more effort exerted to block rescue, the greater the chance is for the suicide to be completed. Impulsive attempts at suicide even with rescuers in sight may be lethal depending on the method. Less lethal methods may include overdosing on aspirin and wrist cutting. Jumping of an 8-foot bridge may cause injury, but it is not likely to be lethal.

The client has tearfully described her negative feelings about herself to the nurse during their last three interactions. Which goal would be most appropriate for the nurse to include in the plan of care at this time? The client will:

verbalize three things she likes about herself Explanation: Describing and verbalizing feelings are necessary and normal because the client has usually repressed or blocked feelings that are partly responsible for the client's pain. Expressing feelings is a prerequisite before the nurse can intervene in how the client thinks or behaves. Asking the client to identify only three qualities is not overwhelming.Stating a goal such as increasing self-esteem is too global and nonspecific.Writing negative feelings in a journal will not benefit the client because she has verbalized them to the nurse and ruminating about them is not therapeutic. Verbalizing work-related accomplishments is too specific and focuses on only one client aspect.