Mental health vati

A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?

"I should call the provider if I experience excessive sweating and muscle twitching" -Sertraline and other selective serotonin reuptake inhibitors can cause serotonin syndrome, characterized by agitation, anxiety, hallucinations, hyperactive reflexes, excessive diaphoresis, and hyperthermia. This condition can cause death; the client should report these findings to the provider so the medication can be safely discontinued.

As part of the plan of care for a client with borderline personality disorder. the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

" don't like it when you address me with that tone of voice." Borderline personality disorder (BPD) is described as an emotionally unstable personality. Clients with BPD may show a wide range of impulsive behaviors in all aspects of their lives, including self-destructive behaviors. The client in this situation has overstepped a limit by addressing the nurse in a less-than-respectful tone of voice. This therapeutic response calls to the client's attention the inappropriate behavior and sets appropriate limits for further communication

A nurse is caring for a 20-year-old college student who reports severe epigastric distress, and a 2-year history of bulimia. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?

"It seems like you are feeling helpless about this behavior." effectively. The nurse is responding to the feelings the client has expressed. Clarifying feelings begins the process of exploring how to deal with them more

A client who is about to undergo a left lobectomy to treat lung cancer tells the nurse that she is scared and wishes she had never smoked. Which of the following is an appropriate nursing response?

"It's okay to feel afraid. Let's talk about what you are afraid of." It is the nurse's responsibility to acknowledge the client's statement, to encourage verbalization, and to explore the client's feelings.

A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

"You seem to be having some very frightening thoughts." The nurse is shifting the focus from the delusional beliefs to the client's fear or feelings the client is attempting to communicate.

A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements should the nurse include in the teaching?

"You should change positions slowly while taking this medication." clients should change positions slowly while taking amitriptyline due to the risk of orthostatic hypotension.

A nurse is reinforcing teaching with a client who is to begin taking a monoamine oxidase inhibitor (MAOI) in addition to a selective serotonin reuptake inhibitor (SSRI). Which of the following statements should the nurse include in the teaching?

"You will need to be off the SSRI for at least two weeks before starting the MAOI." To avoid serotonin syndrome, the client needs to be off all SSRI medication for 2 to 5 weeks before initiating an MAOI.

A nurse is collecting data from a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)

- Delayed language development - Spins a toy repetitively - Ritualistic behavior

A nurse is reinforcing teaching with a client who is to begin taking paroxetine. Which of the following statements by the client indicates an understanding of the teaching?

-I MIGHT NOT FEEL LIKE EATING AS MUCH Anorexia and a decreased appetite are adverse effects of paroxetine.

A nurse is caring for a hospitalized client who has agoraphobia. The nurse observes that the client is making progress when he is able to participate in which of the following activities?

A picnic in a local park Agoraphobia is fear of being in places where help might not be available, such as being outside alone. The park is outside of the hospital, so the client would demonstrate progress by leaving the grounds of the facility to attend a picnic.

A nurse is caring for a client in an urgent care center who has traumatic injuries following an assault. She sits quietly and calmly in the examination room. The nurse should recognize this behavior as which of the following reactions?

Denial Denial is a defensive coping mechanism that protects the client from increasing anxiety levels. The client consciously disowns intolerable thoughts and ideas. It is a common response of victims of violent crimes.

A nurse is assisting with an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following is the highest priority?

Determining if the client has psychotic thinking. Clients experiencing a situational crisis are at greatest risk for injury to themselves or others; therefore, determining if psychotic thinking is present is the highest priority.

A provider tells a client who has an anterior cruciate ligament that he may not play football for the remainder of the season. The client yells that the provider doesn't know what he is talking about and kicks a chair. Which of the following defense mechanisms is the client demonstrating?

Displacement The client is demonstrating displacement when he shifts feelings about an object, person, or situation to another less threatening object, person, or situation. The client transferred his emotional reaction about the injury and inability to play to the provider and to the chair.

A nurse is caring for a client on a psychiatric unit. After nine electroconvulsive therapy (ECT) treatments, the client reports less depression but short-term memory loss. Which of the following is the appropriate nursing action?

Explain that this memory loss is temporary, and the client's memory will return to normal after several weeks. Short-term memory problems are temporary side effects of ECT treatment. While the duration of these memory problems may differ among individuals, it often resolves within several weeks.

A nurse is collecting data from a client who is experiencing alcohol withdrawal delirium. Which of the following is an expected finding? (Select all that apply).

Hallucinations, paranoid , tremors

A nurse is reinforcing teaching with a client about Alcoholics Anonymous (A). Which of the following statements by the client indicates an understanding of the program's basic concepts?

I am powerless over my addiction to alcohol basic concept of AA is that the client is powerless over his addiction to alcohol and therefore needs assistance to overcome the addiction.

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse perform first?

Inspect the cuts for bleeding Inspection of the cuts is the first action the nurse should take when using the nursing process approach to client care.

A nurse at a local mental health center is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate therapeutic response?

It sounds like your having a difficult time

A nurse is caring for a client during admission to an alcohol treatment center. When working with this client, which of the following approaches is appropriate?

Maintain a nonjudgmental attitude. When working with clients who have an addictive disorder it is important that the nurse remain nonjudgmental.

A nurse is assisting with the admission of a client who has a suspected cognitive disorder. Which of the following resources should be included as part of the data collection?

Mini-Mental State Examination (MMSE) The use of a mental status questionnaire assists in identifying deterioration in mental status and brain damage which are findings associated with cognitive disorders.

A nurse is caring for a client who has depression. After three days of treatment the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions is appropriate to recommend including in the plan of care?

Monitor the client's whereabouts at all times. Clients who have depression and exhibit a sudden change in behavior are at risk for suicide and precautions should be included in the plan of care.

A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

Muscle contractions of the neck Fidgeting behavior Impaired gait

A nurse is collecting data from a client who is receiving treatment with multiple antipsychotic medications. Findings include muscle rigidity. hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

Neuroleptic malignant syndrome The client's findings indicate possible neuroleptic malignant syndrome which is a potentially life-threatening adverse effect of antipsychotic medications.

A nurse is assisting is collecting data from a client who has acute phencyclidine (PCP) intoxication. Which of the following findings should the nurse expect?

Paranoia Pcp intoxication causes feeling of paranoia and panic

A nurse is making a home visit for an adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

Planning to give his CD collection to his girlfriend Warning signs of suicide include giving away possessions the person cherishes, talking about his own death, and describing himself as worthless. CONTINUE

A nurse is contributing to the plan of care for a client who has dementia. Which of the following actions should the nurse include in the plan of care?

Provide a consistent daily routine A consistent daily routine is appropriate for the care of a client who has dementia.

A nurse is caring for a client who has schizophrenia and taking haloperidol. The nurse observes that the client has developed a stooped posture and shuffling gait. The nurse should document these findings as which of the following extrapyramidal side effects of haloperidol?

Pseudoparkinsonism Pseudoparkinsonism is an extrapyramidal side effect that includes findings such as a stooped posture, shuffling gait, tremor, drooling, and a mask-line facial expression.

A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following nursing approaches helps establish a therapeutic relationship with this client?

Set aside a specific time each day to spend with the client. ~ CORRECT My Answer Since this client has trust issues, the nurse can demonstrate trustworthiness by setting times to meet with the client and keeping the appointments, It is especially important that the nurse be consistent and on time for the meetings

A client attacked a friend and is admitted to the psychiatric unit. Which of the following actions should the nurse perform first?

Set behavioral limits for the client The nurse should first set behavioral limits for the client to decrease harming others.

A nurse in an urgent care clinic is caring for a client who is using loud and rapid speech, and continuously repeats, "I don't know why my wife left me." Which of the following levels of anxiety is the client experiencing?

Severe Clients who have severe anxiety use loud and rapid speech, and are unable to complete simple tasks. Their focus is on the cause of the anxiety and their behavior is directed at relieving the feelings of dread and fear.

A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). The client states, "I don't care what the doctors say. there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse should identify that the client is experiencing which of the following forms of crisis?

Situational diagnosis of HIV is a situational crisis which is one that is unexpected but is part of regular life, such as a serious illness or financial loss.

A nurse is caring for a client who is taking fluphenazine for schizophrenia. Which of the following findings is the nurse's priority?

Tachycardia Tachycardia indicates that this client is at greatest risk for anticholinergic toxicity: therefore, this is the nurse's priority finding. The nurse should withhold the client's next dose of fluphenazine and contact the provider.

A nurse is caring for a client who has bipolar disorder. Which of the following should be recognized as manic behavior? (Select all that apply.)

Taking in rapid, continuous speech, interacting with others in a filtration way, spending large sums of money

A nurse in a mental health clinic is attempting to develop trust in the nurse-client relationship. Which of the following techniques is appropriate?

The nurse uses consistency in approaching the client Using a consistent approach to client care promotes trust in the nurse-client relationship.

A nurse is collecting data on a client who is experiencing chronic stress, Which of the following is an expected finding?

viral infection Decreased immune response which leads to viral or bacterial infections in response to chronic stress

nurse is caring for a client who has anorexia nervosa. The client refuses a high-calorie nutritional supplement. Which of the following ethical principles is the nurse utilizing when respecting the client's decision?

autonomy Respect the rights of clients to refuse medication or treatment

A nurse caring for a client on a mental health unit who has been prescribed a conventional antipsychotic medication. The nurse should know that the tardive dyskinesia that can occur as an adverse effect of this medication

can interfere with a dient's ability to eat. My Answer Tardive dyskinesia is a serious movement disorder that can significantly affect the muscles of a client's tongue and mouth.

A nurse suspects that a client who has Alzheimer's disease is unconsciously telling untrue stories to protect her self-esteem. This nurse correctly identifies this behavior

confabulation. This behavior is correctly identified as confabulation

A nurse is collecting data on an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion?

eat one piece of candy, kmay as well eat The client's statement is an example that displays All-or-Nothing Thinking, which is a form of cognitive distortion.

A nurse is collecting data from a client who has hypomania. Which of the following findings should the nurse expect?

euphoria A client experiencing hypomania often experiences a sense of euphoria

A nurse at a mental health facility is discussing antidepressant medications with a newly licensed nurse, comparing selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Which of the following information should the nurse include about TCAs?

increased risk of cardiovascular adverse effects TCAs can cause cardiac dysrhythmia and can be lethal to the client in the event of overdose. The nurse should include that clients should undergo cardiac screening before beginning therapy and have periodic ECG analysis while taking this medication.

nurse is evaluating a client whose 12 year old child was killed in a motor vehicle crash involving a drunk driver 2 years ago. Manifestations of dysfunctional grieving are evident if the parent

leaves the child's room exactly as it was before the loss. Grieving becomes dysfunctional when a client is unable to resume regular activities of daily living or experience emotions other than sadness or depression. This is an example of dysfunctional grieving.

nurse is reinforcing teaching about valproate with a client who has a bipolar disorder. Which of the following information should the nurse include in the teaching?

liver function test must be monitored regularly Hepatotoxicity is rare, but serious adverse effect, therefore liver function tests must be performed

nurse is reinforcing teaching with the family of a client who is prescribed haloperidol decanoate IM every 4 weeks. Which of the following manifestations should the nurse instruct the family to monitor for to determine effectiveness of the medication?

moroved attention span Haloperidol decanoate is a depot or long-acting antipsychotic medication prescribed for clients who have schizophrenia. Cognitive manifestations associated with acute schizophrenic episodes include inattention, impaired memory, and illogical thinking. Therefore, the nurse should instruct the family to monitor for an improvement in the client's cognitive ability as evidence of the effectiveness of the medication.

A nurse is caring for a school-age child who has a terminal illness. His parents tell the nurse they have reluctantly taken the child's name off the list for participating in baseball this year. Which of the following responses should the nurse make?

must be frustrating for you to have to cancel an activity your son enjoyed." This response demonstrates the therapeutic communication technique of sharing empathy. It is neutral and nonjudgmental and invites further communication and sharing.

A nurse is caring for a client who washes her hands repeatedly and almost constantly. The nurse should recognize the client's actions as which of the following?

relieving the clients anxiety A client who has obsessive compulsive disorder repeatedly performs ritualistic behaviors as a way to alleviate anxiety.

A nurse is caring for a client who has major depressive disorder. Which of the following actions should the nurse take when developing a relationship with the client?

set boundaries with the client regarding personal space Setting clear boundaries regarding the nurse-client relationship is important in order to fet the client know how the relationship with progress. Boundary setting includes discussing confidentiality, roles, the physical environment, and appropriate physical space

A nurse is discussing suicide interventions with a newly licensed nurse. Which of the following statements indicates an understanding of tertiary intervention?

should provide counseling for the family following the suicide of a client Providing counseling for the family following the suicide of a client is an example of tertiary intervention,

A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

whether the client is a danger to herself or others Clients who have mental health issues can be admitted for care voluntarily or involuntarily. The criteria for involuntary admission includes a statement of a legal opinion that the client has a mental health disorder that will likely result in serious bodily harm to the client, or another person, unless the client remains in a psychiatric facility.