mental health

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is which?

1. Feed, bathe, and dress the client as needed until the client can perform these activities independently.

The nurse is caring for a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis?

3. Makes excuses for not leaving the house

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be nontherapeutic? Select all that apply.

3. Minimizing feelings 4. Changing the subject 5. Asking "why" questions

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

1. "I notice you are wearing a blue shirt." 2. "Do you have any plans of harming yourself?" 4. "I will sit here with you even if you choose not to talk with me."

The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply.

1. Provide high-calorie finger foods. 2. Decrease the light and noise level on the unit. 3. Restrict the client's access to money and other valuables.

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.

1. Reinforce the client's problem-solving abilities. 4. Assess "secondary gains" that the somatic illness provides the client.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.

1. Restating 2. Listening 4. Maintaining neutral responses 6. Providing acknowledgment and feedback

The registered nurse has written an outcome statement of "Client will feel less anxious by the end of session" for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

1. Stay with the client. 3. Administer anxiolytics medications if prescribed. 4. Ensure the client is in an environment with little stimuli.

The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply.

2. "I hid my silverware from dinner last night." 5. "I know that by this time tomorrow all my troubles will be over."

The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?

2. "Let me know if you change your mind, and I'll get you something to eat."

The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa?

2. A high achiever 4. Personality changes 5. Lanugo over the back and extremities IncorrectCorrect Answer: 2,4,5

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.

2. Client threatened to commit suicide. 3. Client threatened to kidnap his spouse.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

2. Contact the health care provider (HCP).

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which?

3. "Are you fearful and think that others may want to hurt you?"

During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic?

3. "I can see that you are upset about this. Let's talk about this some more."

The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply.

3. Request that the client perform undemanding, self-care tasks. 4. Reinforce teaching the client techniques to maintain present reality. 5. Assist the client to reestablish relationships with significant others.

The nurse working in a mental health unit hears that a client has been experiencing "flashbacks." The nurse interprets that this client is exhibiting a sign of which condition?

4. Posttraumatic stress disorder (PTSD)

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

2. Incoordination 4. Mental confusion 5. Muscle hyperirritability

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.

2. Risk for injury 4. Risk for infection 5. Risk for aspiration 6. Impaired verbal communication

A woman comes into the emergency department following an assault. She presents with hyperventilation, pacing, rapid speech, and headache. The nurse correctly determines that the client is experiencing which level of anxiety?

2. Severe

The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

2. The client asks to meet with a lawyer to take care of unfinished business.

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?

3. "It must be frightening to you. Has something made you feel that your food is poisoned?"

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

4. A client who could benefit from the client's assistance at mealtimes

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice?

4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

The client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening and shouting at everyone, and is refusing to participate in therapy. The nurse takes which initial action?

4. Provide for safety by recognizing the level of client anxiety and setting limits.