MH Nursing Final

A nurse is providing education for a client who will begin taking alprazolam (Xanax) for anxiety. Which statements should the nurse include in the discussion? (Select all that apply.)

"Be particularly careful going up and down stairs since you will be more prone to falling." "If you experience sight problems like blurred vision, we need to know that immediately."

Fluoxetine hydrochloride is prescribed for a client being treated for depression, and the nurse reinforces instructions to the client regarding the medication. Which statement by the client would indicate that the client understands this medication therapy?

"It takes approximately 2 to 4 weeks before improvement is noted."

According to Freud's psychosexual theory, the ego has several functions. A newly hired nurse asks the nurse mentor what is the primary function of the ego. How does the nurse mentor respond?

"Its prime function is to test reality and direct behavior."

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.

Which of the following clients would require additional health teaching regarding the effects of a prescribed benzodiazepine drug agent?

32-year-old who smokes two packs of cigarettes a day.

To be diagnosed with generalized anxiety disorder, the client must have had symptoms on most days for at least:

6 months

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?

A client receiving diagnostic tests

A nurse is caring for a patient taking haloperidol (Haldol). What is a common side effect the nurse may see?

A) Anxiety B) Weight loss C) Sedation D) Dry mouth

When assisting with developing the plan of care for a client diagnosed with a dissociative disorder, which treatment would the nurse expect to include? Select all that apply. Question options:

A) Electroconvulsive B) Cognitive C) Creative art D) Hypnosis E) Antidepressant

When reviewing a care plan of a client diagnosed with obsessive-compulsive disorder, the nurse should expect to see which nursing intervention early in treatment?

A) Increasing stimuli in the environment B) Setting strict limits on the amount of time spent performing the ritual C) Allowing time for the client to perform the ritual D) Preventing all ritualistic behaviors

A client has reported that crying spells have been a major problem over the past several weeks that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment?

A) Medication compliance B) Sleep pattern C) Weight loss D) Onset of the crying spells

A nurse is reading a journal article about neurotransmitters and their role in depression. The nurse demonstrates understanding of the information when the nurse identifies depression as being associated with a deficit in which neurotransmitter? Select all that apply.

A) Norepinephrine B) Dopamine C) Serotonin D) Tyramine E) GABA

A nurse is caring for a patient diagnosed with agoraphobia. The nurse understands this means:

A) Obsessive-compulsive behavior B) Fear of physical pain C) Fear of being alone D) Aggressive behavior

The nurse is caring for a patient with bipolar disorder who is currently in the manic phase and is trying to get the patient involved in diversional activity. Which of the following would be the most appropriate activity?

A) Ping-pong B) Jigsaw puzzle C) Exercise class D) Bridge

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?

A) Poor dietary choices B) Inadequate dietary intake and dehydration C) Lack of exercise and poor diet D) Psychomotor retardation and side effects of medication

The nurse is performing a follow-up session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to the medication?

A) Problems with mouth dryness B) Problems with excessive sweating C) Gastrointestinal dysfunctions D) Cardiovascular symptoms

The nurse is reinforcing rules and boundaries to a newly admitted client. These actions are part of which phase of the therapeutic relationship?

A) Working B) Orientation C) Termination D) Pre-interaction

During which phase of the therapeutic relationship should the nurse begin preparing the client for termination of the relationship?

A) during the initial meeting B) at the midpoint of the relationship C) at the time of discharge D) when the client can function independently

The nurse is caring for a client with depression who tells the nurse about a new romantic relationship. The client states that the partner has a "temper." Which information about the partner will help the nurse determine the degree of risk that the client's new partner may abuse the client? Select all that apply.

A) engages in problematic alcohol or other substance use B) comes from a home with a history of domestic violence C) has a lower or unreliable income D) is much older than the client E) has a wide circle of same-gender friends

Maintaining client confidentiality:

A) is always followed throughout the length of the relationship B) is an essential element in establishing a meaningful nurse-client therapeutic relationship C) does not influence your communication with your peers D) does not influence communication with client's significant others

A 33 y/o pt is admitted to a psych facility w/ a medical Dx of MDD. When the nurse is assigning the pt to a room, which roommate is best for this pt?

A. A 35-year-old client who recently attempted suicide B. A manic client who has started lithium carbonate treatment C. A client who is bipolar and is pacing the floor while telling jokes to everyone D. A paranoid client who believes that the staff is trying to poison the food

A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor?

A. Authority issues in childhood B. Anger about being hospitalized C. Low self-esteem D. Phobia of food

Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.)

A. Importance of adherence to medication regimen B. Current treatment measures for substance abuse C. Signs and symptoms of an exacerbation D. Prevention of criminal activity E. Behavior modification for aggression F. Chronic grief associated with long-term illness

A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior?

A. Move all medical equipment away from the client's bedside. B. Allay fears by teaching the client about the causes of the disease. C. Cluster care to allow for brief rest periods during the day. D. Encourage visitation by the client's family members, including the client's young children.

A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take?

A. Notify the health care provider immediately and force fluids. B. Prior to giving the next dose, notify the health care provider of these symptoms. C. Record the symptoms and continue with medication as prescribed. D. Hold the medication and refuse to administer additional doses.

The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal?

A. Psychomotor agitation B. Restlessness and hyperactivity C. Detachment from reality and drowsiness D. Distorted perceptions and hallucinations

A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?

A. Sublimation B. Identification C. Introjection D. Repression

Over a period of several weeks, one participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?

A. Talk to the client outside the group about his behavior. B. Ask the client to give others a chance to talk. C. Allow the group to handle the problem. D. Ask the client to join another group.

A client with schizophrenia has been started on medication therapy with loxapine. The nurse determines that the client is experiencing the intended effects of the medication if which client behavior is observed?

Absence of delusional statements

A client's medication sheet contains a prescription for sertraline hydrochloride. To ensure safe administration of the medication, which action should the nurse take?

Administer at the same time each evening

The nurse is reinforcing medication discharge instructions for a client who has just begun taking isocarboxazid for depression and knows that the client needs further teaching after stating that which foods are safe to eat? Select all that apply.

Avocado Bologna

A client has begun taking phenelzine. At the initiation of therapy, the nurse teaches the client that which items are allowed in the diet?

Carrots, sweet potatoes, and squash

A patient complains of trouble with control of her or his tongue. Also, the neck muscles are beginning to tighten and the patient is having difficulty keeping her or his head in an upright position. The nurse's first response should be:

Check the medication administration record

The nurse is reviewing a care plan for a client diagnosed with schizophrenia who has been prescribed an antipsychotic medication. The nurse would expect to find which priority outcome for this client?

Compliance with therapeutic drug regimen

A client has a history of seizures. The primary health care provider has prescribed amitriptyline three times daily. The nurse seeks clarification of the prescription, knowing that the client is at risk for injury because of which adverse effect of the amitriptyline?

Decreased seizure threshold

The nurse understands that the primary purpose of diagnostic testing for a client diagnosed with any dissociative disorders is to:

Determine if there are any coexisting physical conditions.

An older mental health client diagnosed with chronic neuropathic pain is starting therapy with a tricyclic antidepressant called imipramine hydrochloride. The client is complaining of constipation. The nurse knows that which signs/symptoms are other adverse effects of this medication? Select all that apply.

Dry mouth Drowsiness Acute confusion Urinary retention

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply

Encourage expression of feelings, concerns, and fears Be honest and truthful and let the client and family know that you will not abandon them Extend touch, and hold the client and family member's hand if appropriate Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? Select all that apply.

Figs Yogurt Aged cheese

A nurse is gathering data about a client diagnosed with schizophrenia. Which finding would the nurse identify as a negative symptom?

Flat affect

A client admitted to the hospital gives the nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?

Frequent hand washing with hot, soapy water

A client diagnosed with agoraphobia associated with panic disorder has been unable to leave her home for the last 6 months. In reviewing the care plan, the nurse should expect to find which goal for this client?

Function effectively within the environment

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to the medication?

Gastrointestinal dysfunctions

A client is being treated for depression with amitriptyline hydrochloride. During the initial phases of treatment, which is the most important nursing intervention?

Getting baseline postural blood pressures before administering the medication and each time the medication is administered

The nurse is monitoring a client taking an antipsychotic medication for signs/symptoms of neuroleptic malignant syndrome (NMS). The nurse should expect to note which sign/symptom if NMS occurred?

Hyperpyrexia

A client is being seen for increasing symptoms of panic attacks. The client asks the physician for "something for my nerves." Which of the following comments by the client should the nurse report to the physician?

I am happiest when I am breast-feeding my 2-month-old daughter.

A client is experiencing acute delirium. Which intervention would the nurse identify as the priority for this client?

Initiate safety precautions.

A nursing student is assigned to care for a client with a diagnosis of schizophrenia. Haloperidol is prescribed for the client, and the nursing instructor asks the student to describe the action of the medication. Which statement by the nursing student indicates an understanding of the action of this medication?

It blocks the binding of dopamine to the postsynaptic dopamine receptors in the brain.

The nurse is doing patient teaching for a client taking a newly prescribed antianxiety medication. Which statement by the client would alert the nurse to the need to do further teaching?

Maybe now I can enjoy an evening of wine and dinner with my wife.

A client taking buspirone for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness?

No rapid heartbeats or anxiety

A tricyclic antidepressant is administered to a client daily. The nurse plans to alleviate the common side effects of the medication and includes which in the plan of care?

Offer hard candy or gum periodically.

A client receiving an anxiolytic medication complains that he feels very "faint" when he tries to get out of bed in the morning. The nurse explains to the client that which side effect is associated with this type of medication? Postural hypotension

Postural hypotension

Identification

RATIONALE:Identification is an attempt to be like someone or emulate the personality traits of another.

A client has been started on medication therapy with alprazolam. When the nurse teaches the client that the medication should not be discontinued abruptly, the client asks why. The nurse should incorporate which information in formulating a reply?

Rebound central nervous system (CNS) excitation could occur, including seizure activity.

A client receiving long-term therapy with lithium carbonate has a toxic serum lithium level of 1.5 and 2 mEq/L. Which organ functions are the major long-term risk factors? Select all that apply.

Renal functionThyroid function

A client is receiving lithium carbonate. The client's lithium carbonate level is 1.5 mEq/L, which indicates an early sign of toxicity. Which are some early signs/symptoms of toxicity? Select all that apply.

Slurred speech Muscle weakness Lethargy 0.7 mEq/L Diarrhea 1.0 mEq/L

The nurse is caring for a client on the mental health unit who has been declared incompetent through a formal legal proceeding. A guardian has been appointed. The nurse knows that guardians are typically selected from among family members. From the list of family members, what is the order of selection of a guardian for this client? List in descending order of importance from the first to the last choice. All options must be used.

Spouse; Adult Children/grandchildren; Parents; Adult siblings; Adult nieces/nephews

A client is taking a monoamine oxidase (MAO) inhibitor. The nurse plans care, knowing which information?

Symptomatology of MAO toxicity includes headache, hypertension, and nausea and vomiting.

A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up, and the level is 3.0 mEq/L (3.0 mmol/L). The nurse knows that this is which level?

TOXIC

A nurse enters a patient's room and stands just inside the door. The patient is obviously agitated and is escalating to the point that physical harm may occur. What would be the nurse's most appropriate action?

Talk to the patient and try to identify why he or she is so agitated

A client is exhibiting lip smacking, facial grimacing, and protruding tongue movements. The nurse would document these extrapyramidal side effects using which term?

Tardive dyskinesia

A client in the mental health unit is administered haloperidol. What should the nurse check to determine its effectiveness?

The client's orientation and delusional status

A client who is taking lithium carbonate is scheduled for surgery. The nurse would reinforce what information in the preoperative teaching about this medication?

The medication will be discontinued 1 to 2 days before the surgery and resumed as soon as full oral intake is allowed.

The nurse is caring for a client who is receiving lithium carbonate for the treatment of bipolar disorder and monitors the client for signs/symptoms of lithium toxicity. Which sign/symptom should alert the nurse to the potential for toxicity?

Vomiting

A hospitalized client is started on phenelzine sulfate for the treatment of depression. At lunchtime, a tray is delivered to the client. Which food item on the tray should the nurse remove?

Yogurt

The nurse distinguishes that which assessment data will most influence a client in crisis?

previous coping skills

A client was the lone survivor of a train crash 6 months ago. Which statement by the client would indicate a maladaptive response to the trauma?

"I don't want to talk about it."

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement?

"I no longer feel that I deserve the beatings my husband inflicts on me"

Fluoxetine is prescribed, and the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about the administration of this medication?

"I should take the medication in the morning when I first arise."

Which statement demonstrates the nurse's use of focusing when communicating with a client about relationships with family members?

"Let's get back to how you feel about your son's decision to leave school."

A manic client begins to make sexual advances toward visitors in the day room. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?

1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests no autopsy be performed. Which response to the family is most appropriate?

1."The decision is made by the medical examiner." 2."An autopsy is mandatory for any client who is DOA." 3."I will contact the medical examiner regarding your request." 4."It is required by federal law. Tell me why you don't want the autopsy done?"

The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action?

1.Provide a dark room. 2.Provide a well-lighted room. 3.Reorient the client every 8 hours only. Rationale: Delirium may occur during the last days of life. Nursing management of a terminally ill client experiencing delirium includes providing a room that is quiet, well lighted, and familiar to reduce the effects of delirium; reorienting the dying client to client, place, and time with each; and administering prescribed benzodiazepines and sedatives as needed.

What response best teaches the client about the events and outcome expected with electroconvulsive therapy treatment?

A) "Electrodes deliver an electrical shock that positively affects your symptoms." B) "A seizure that lasts only a few seconds causes your mental disorder to improve." C) "A controlled seizure occurs that helps to restore a chemical balance in the brain." D) "Medication is used to prevent severe muscle contractions and it is over in a few minutes."

The nurse is interacting with a patient with obsessive compulsive disorder. What statement by the patient may validate that certain activities help her to deal with her anxiety?

A) "I am willing to take medication if necessary" B) "I worry about the health of my aging parents" C) "I have a stupid problem, don't I" D) "I worry about dirt and germs and I clean a lot"

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?

A) "I'll go to a support group and talk so that I won't hurt anyone" B) "My medications won't make me anxious" C) "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone" D) "I won't get anxious or hear things if I get enough sleep and eat well"

Which statement by the nurse demonstrates an understanding of the impact of personal space on a conversation?

A) "It's important to keep out of the personal space of a client who is angry." B) "The client appears more relaxed and willing to talk when we sit across from each other at the table." C) "I've explained the concept of personal space to the clients so they can learn to respect each other effectively." D) "Personal space is usually considered to be 2 to 4 ft around the individual."

The nurse is teaching a client who is at risk for violence from a domestic partner about how to create an escape plan from the home. What information does the nurse include? Select all that apply.

A) "Plan an escape route out of your home in case you need to leave quickly." B) "Prepare a bag of clothing, identification, and cash that you can easily grab when needed." C) "Always keep the contact information of women's shelters somewhere readily accessible." D) "Inform your partner that you are fully prepared to leave if you feel threatened or unsafe." E) "Have a bank account created in your own name that is not accessible by your partner."

A patient is admitted to a psychiatric unit following an unsuccessful suicide attempt. He repeatedly tells the nurse, "I want to die, please help me die". The most appropriate nursing response is:

A) "You must be feeling very sad right now" B) "Relax, nobody's going to kill you" C) "Why do you want to die?" D) "Don't worry, you're safe here"

The nurse is completing discharge instructions for a patient being discharged on Antabuse to help avoid using alcohol. Which of the following statements should the nurse include in the teaching?

A) "You will need bi-weekly blood work to determine blood levels of the medication" B) "The Antabuse can cause you to be sensitive to the sunlight" C) "The Antabuse can stay in your system as long as 14 days after you stop taking the medication" *

A nurse who is doing discharge teaching for a patient on antidepressant therapy should tell the patient he could expect to feel better in what length of time?

A) 5-7 days B) 2-3 days C) 2-4 weeks D) 4-6 weeks

Paranoid thinking is characterized by feelings of:

A) Anger and aggression B) Simultaneous hero worship and hero hating C) Suspicion and jealousy D) Self-pity and self-centeredness

A client is experiencing extrapyramidal side effects secondary to prescribed antipsychotic therapy. The nurse anticipates which drug class as being used most commonly to relieve these effects?

A) Anxiolytics B) Antihypertensives C) Anticonvulsants D) Antiparkinson

Suicide is most likely to occur:

A) As the depression lifts B) On discharge C) As the depression deepens D) On admission

The nurse is working on an inpatient psychiatric unit with clients with post-traumatic stress disorder. Clients are at risk of requiring physical restraint due to severe agitation and the potential for harm to self, other clients, and staff. Which action(s) should the nurse take to reduce the use of restraints in this population? Select all that apply.

A) Assess the knowledge of unit staff about the safe application and monitoring of physical restraints. B) Advocate for regular reinforcement of de-escalation technique training with all staff on the unit. C) Show the clients the type of restraints that will be used if the client is deemed to be a risk to self or staff. D) Ensure all clients have PRN prescriptions for intramuscular (IM) antianxiety medications or sedatives. E) Inform clients immediately when they display signs of moderate anxiety

The nurse is addressing the needs presented by a woman who has just left an abusive spouse. The nurse would initially focus on which area?

A) Assuring the client that she is not to blame for the abusive situation that exists B) Recognizing the effects such abuse has on a client C) Arranging for the client to attend a therapy group dealing with domestic abuse D) Working with the client to identify a safe place to live

A patient with a personality disorder is brought to the outpatient clinic by her mother, who states her daughter is out of control. The nurse should begin to foster trust by:

A) Avoiding the establishment of trust because the relationship will eventually be terminated B) Telling her you care about her but may not always approve of her behavior C) Telling her you are available regardless of her behavior D) Letting her know she can call you day or night

A client suddenly becomes unable to recognize who the client is and cannot recognize family members. The client is most likely experiencing which condition?

A) Dementia B) Conversion disorder C) Trauma-induced amnesia D) Dissociative disorder

A nurse is reviewing the plan of care for a client with substance abuse. Which statements would the nurse identify as reflecting expected outcomes specifically focused toward long-term sobriety? Select all that apply.

A) Demonstrates willingness to participate in a group recovery treatment program. B) Identifies non--substance-focused coping mechanisms to use in response to stress. C) Identifies necessary lifestyle changes. D) Verbalizes understanding of illness and the recovery process. E) Decreases anxiety and promotes relaxation.

A client's history reveals a mood disorder that is less severe than major depressive disorder but is recurrent and part of the client's everyday experience. The nurse would identify this as which condition?

A) Dysthymic B) Cyclothymic C) Mania D) Bipolar

When providing nursing care for a child exhibiting suicidal ideations, which intervention should take priority for this client?

A) Establishing a consistent pattern of reward for positive behavior B) Maintaining a safe environment C) Establishing a trusting relationship

A nurse institutes seizure precautions for a client experiencing acute substance withdrawal. At which frequency would the nurse perform this intervention?

A) Every shift B) Every 1 hour C) Every 15 minutes *

The nurse intends to implement limit setting for a client who is manipulative. Which intervention would be most appropriate to use initially?

A) Explaining the expected outcome of the boundary setting B) Recognizing what the client is attempting to do as being controlling C) Applying firm but fair boundaries D) Focusing on the feelings the client is currently feeling

When reviewing the history, the nurse notes that the client stated, "I spend so much of my time and money on doctor visits and the doctor still doesn't know what is causing my pain. But I know there is something seriously wrong." The nurse interprets this statement as reflecting which medical diagnosis?

A) Factitious disorder B) illness anxiety disorder C) Somatic symptom disorder D) Conversion disorder

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that appy.

A) Follow through about the consequences of behavior in a non-punitive manner B) Assist the client with developing a means of setting limits on personal behavior C) Be clear with the client regarding the consequences of exceeding limits set regarding behavior D) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups E) Communicate expected behaviors to the client F) Ensure that the client knows that he or she is not in charge of the nursing unit

A nurse is gathering data about a client potential for risk domestic violence. When reviewing the client's history, which information would the nurse identify as being important? Select all that apply.

A) Has been arrested for intentionally breaking the neighbor's windows. B) Made the statement, "Women need to stay home and raise the children." C) Reported, "My dad beat us with a belt when we didn't obey him." D) Coaches a children's elementary school soccer team. E) Has a history of drug abuse.

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

A) Have the client's peers confront the client about how their noncompliance with addressing activities of daily living affects the milieu B) Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living C) Feed, bathe, and dress the client as needed until the client can perform these activities independently D) Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living

A hospitalized schizophrenic patient who experiences auditory hallucinations is placed on clozpine (Clozaril) by his physician. The nurse knows the medication is effective when the patient reports that:

A) He no longer hears voices B) The voices aren't as loud C) He does not disturb the other patients any more D) He is too drowsy to concentrate on the voices

A nurse is assisting with the development of a plan of care for a client diagnosed with a somatic symptom disorder. Which intervention would be the initial priority? Question options:

A) Identifying positive feelings that the client may have B) Helping the client face responsibilities C) Providing a comfortable environment D) Responding to the client with patience and understanding

A nurse is reviewing the medical record of a client diagnosed with an eating disorder Which assessment data would the nurse identify as supporting this diagnosis? Select all that apply.

A) Increased fatigue B) Intolerance to cold C) Reports of insomnia D) Intolerance to heat E) Increased anxiety level

The nurse is reviewing the discharge education for the family of an older client who was hospitalized for treatment of delirium. Which information should the nurse reinforce to minimize the future risk of developing delirium again? Select all that apply.

A) Know characteristic signs and symptoms of infection in the older population. B) Check with the client's health care provider before introducing any new medications. C) Be familiar with the adverse reactions for all the medications the client is prescribed. D) Assure that the client has a consistent, predictable daily routine. E) Help assure the client maintains an adequate fluid intake to remain well hydrated.

A nurse is gathering data from a client who is suspected of having an illness anxiety disorder. Which findings would support this suspicion? Select all that apply.

A) Loss of pain or touch sensation B) Statements reflecting obsession that an illness exists C) Concerns continue despite medical testing and reassurance that a disease does not exist D) Disproportionate level of anxiety and worry even if symptoms are minor E) Visits to numerous health care providers for the same problem

To foster a sense of safety in a client demonstrating paranoid behavior, which nonverbal technique should the nurse implement?

A) Making an effect to establish intermittent eye contact when speaking with the client B) Routinely patting the client's shoulder when administering medications to the client C) Purposefully keeping arms uncrossed when engaging the client in a conversation D) Respecting an extended area of personal space when interacting with the client E) Routinely patting the client's shoulder when administering medications to the client

The nurse is interviewing a client diagnosed with avoidant personality disorder. The nurse would expect this client to exhibit which behavior?

A) Manipulation B) Preoccupation with details C) Inability to make decisions D) Extreme shyness

A nurse is providing care to a client newly diagnosed with an eating disorder. The nurse assesses the client's bowel elimination and urine output for which reason?

A) Multisystem organ failure is common with this diagnosis. B) Laxative or diuretic use is commonly associated with this diagnosis. C)Disruption of all organ systems occurs as a result of this condition.

A client taking buspirone for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness?

A) No thought broadcasting or delusions B) No reports of alcohol withdrawal symptoms C) No rapid heartbeats or anxiety D) No paranoid thought processes

An intoxicated client is brought to the emergency department by local police. The client is told that the primary healthcare provider (PHCP) will see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention?

A) Offer to take the client to an examination room until he or she can be treated B) Inform the client that he or she will be asked to leave if the behavior continues C) Attempt to talk with the client to de-escalate the behavior D) Watch the behavior escalate before intervening

A client diagnosed with agoraphobia associated with panic disorder has been unable to leave the home for the last 6 months. In reviewing the care plan, which goal would the nurse expect to find?

A) Participate in psychotherapy B) Control symptoms C) Function effectively within the environment D) Perform self-care activities

To manage the risk of relapse for the client diagnosed with a paraphilia disorder, the nurse includes which interventions in the client's plan of care? Select all that apply.

A) Participating in a 12-step program B) Attending a daily support group C) Taking a daily inventory of thought processes D) Collaborating with the mental health care team E) Isolating the client from the milieu for the client's own safety

A nurse is caring for a patient experiencing manic behavior who is too distracted to eat. The most appropriate nursing intervention should be to:

A) Plan mealtime as a social event B)Plan for meals that include the patient's favorite foods C)Provide a calm mealtime D)Offer finger foods that the patient can eat on the go

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care?

A) Provide the clients on the unit with a sense of comfort and safety B) Assist the staff with caring for the client in a controlled environment C) Provide safety for the client and other clients on the unit D) Offer the client a less-stimulating area to calm down and gain control.

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!

A) Providing acknowledgment and feedback B) Maintaining neutral responses C) Restating D) Asking the client "Why" E) Giving advice, approval, or disapproval F) Listening

During the termination phase of the nurse/patient relationship the patient abruptly gets up and leaves. The most appropriate nursing action should be to:

A) Remain at the interaction site until the end of the contracted time B) Speak with the head nurse about assigning another nurse to the patient C) Go after the patient and bring him back D) Resume her regularly scheduled activities

The charge nurse in a long-term care facility finds one of her elderly patients in a confused state this morning. To help with the patient's orientation, the nurse should:

A) Repeatedly explain to the patient he is in a nursing home B) Mark the patient's room with his name C) Involve the patient in group therapy D) Move the patient to a room near the nurse's station

Which information should the nurse reinforce with a client about the newly prescribed antianxiety medication? Select all that apply.

A) Report any easy bruising or bleeding to your health care provider immediately. B) Know that increased restlessness is a temporary side effect that disappears in a few days. C) Do not combine the medication with over-the-counter (OTC) pain medications. D) Avoid smoking because it increases the sedative effects of the medication. E) Be alert for common side effects that include confusion and loss of coordination.

After obtaining data about a client, which assessment data best support the suspicion that a client possesses what is medically referred to as an anger trait?

A) Reports "being bullied by both my father and my older brothers" B) Several knuckles are bruised and scratched C) History of arrests for assault and battery D) Statements about being "sort of a hot head most of my life"

The nurse is working with a client who has made a sexually inappropriate remark. To maintain appropriate professional boundaries while continuing to preserve a therapeutic nurse-patient relationship, the nurse will initially implement which intervention?

A) Respond to the statement by immediately terminating the conversation with the client. B) In a direct manner, explain immediately why the remark was unacceptable and disturbing. C) Explain that other staff members will assume the responsibility of interacting with the client. D) Explore with the client what the underlying issue is that allowed the statement to be made.

The nurse best assures the positive forward progression in the client's treatment process by addressing which client need?

A) Sense of power and self-control B) Alternative activities to thoughts of self-injury C) Safe and trusting environment D) Therapeutic relationship

The nurse is caring for an elderly patient diagnosed with dementia. The nurse tells the patient to "brush her teeth". The patient doesn't seem to comprehend the instructions. What should the nurse do next?

A) Show the patient the toothbrush B) Try again later in the day C) Tell the patient again

A client is prescribed a new medication, haloperidol (Haldol), for chronic schizophrenia. Assessment reveals muscular rigidity, hyperthermia, and an altered level of consciousness. The nurse identifies these findings as suggestive of which condition?

A) Tardive dyskinesia B) Dystonia C) Neuroleptic malignant syndrome D) Akathisia

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention?

A) Tell the client that smoking privileges are revoked for 24 hours B) Orient the client to time, person, and place C) Escort the manic client to his or her room D) Tell the client that the behavior is not appropriate

A client is hospitalized for substance abuse intoxication. Which data would be a priority during the admission assessment?

A) The client's perception of the admitting problem* B) Genetic factors C) Drug use history

A nurse is assisting in developing the plan of care for a client exhibiting substance abuse behaviors. When reviewing the client's family history, which action would the nurse identify as an example of how the client's family unintentionally contributes to the continuation of the client's substance-abuse behaviors?

A) They exhibit fearful behaviors when the drug user is not around. B) They display defensive actions to excuse the behavior of the drug user. C) They assume responsibility for the problem.

A nurse is caring for a patient with bulimia. The patient tells the nurse she has been bulimic for the past 5 years. In assessing the patient the nurse hears about the following complaints:

A) Toothache B) GI upset C) Sore throat*

A client is experiencing a panic attack. Which interventions would the nurse most likely implement? Select all that apply.

A) Touching the client gently B) Encouraging the client to relax C) Maintaining a calm environment D) Communicating in a nonthreatening manner E) Providing a safe environment

How does the nurse use communication to best effect mental health care for a client diagnosed with a mental illness?

A) Using therapeutic communication to build a trusting nurse-client relationship B) Communicating with the client on a regular basis to demonstrate availability C) Observing the client's verbal and nonverbal communication to update assessment data D) Sharing client-focused information with the health care team

A client arrives at the health care clinic and tells the nurse that they have been doubling their daily dosage of bupropion hydrochloride to help them get better faster. The nurse understands that the client is now at risk for which problem?

A) Weight gain B) Insomnia C) Orthostatic hypotension D) Seizure activity

A nurse uses silence to demonstrate which behavior? Select all that apply.

A) Willingness to listen B) Mastery of therapeutic communication C) Understanding of the client's needs D) Control over the conversation E) Respect for the client's conversation

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining this client?

A) checking that the restraints have been applied correctly B) asking if the client needs to use the bathroom or is thirsty C) reviewing facility policy regarding how long the client may be restraine D) preparing an as-needed dose of the client's psychotropic medication

A nurse immediately tells the truth about a medication error that she made. This nurse is following which ethical principle?

A) veracity B) fidelity C) beneficence D) respect

A newly admitted adolescent on the unit has taken on the mannerisms and hair style of a popular singing star. The nurse recognizes this as an example of:

A)Compensation B) Identification C) Conversion D) Displacement

A middle-aged adult was discharged from a Tx center 6 weeks ago following Tx for SI and ETOH abuse. In a follow-up visit to the mental health clinic, the pt complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask?

A. "Are you taking prescribed antidepressants?" B. "How much alcohol do you consume daily?" C. "What seems to precipitate the anxious feelings?" D. "How many hours do you sleep per day?"

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern?

A. "I don't believe this is true." B. "The guards are not out to kill you." C. "Do you feel afraid that people are trying to hurt you?" D. "What makes you think the guards were sent to hurt you?"

A 38 y/o pt is admitted w/ a Dx of paranoid schizophrenia. When the lunch tray is brought to the room, the pt refuses to eat and tells the nurse, "I know you are trying to poison me w/ that food." Which response by the nurse is the most therapeutic?

A. "I'll leave your tray here. I am available if you need anything else." B. "You're not being poisoned. Why do you think someone is trying to poison you?" C. "No one on this unit has ever died from poisoning. You're safe here." D. "I will talk to your health care provider about the possibility of changing your diet."

A client who has been hospitalized for 2 weeks for paranoia reports continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on the client's complaints?

A. Enroll the client in an exercise class to promote positive activities. B. Place a lock on the client's closet to allay the client's concerns. C. Promote extinction of the ideation by ignoring the client. D. Explain to the client that these suspicions are certainly false.

An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently exposes his/her body to other residents. Which intervention should the nurse implement?

A. Establish a one-to-one relationship to discuss the behavior. B. Redirect the client to physically demanding activities. C. Encourage the client to verbalize thoughts when acting out. D. Restrict social interactions with other residents in the facility.

A pt on the psych unit, Dx w/ bipolar d/o, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take?

A. Have the staff escort the client to his room. B. Tell the client that his behavior will be documented in his record. C. Redirect the client by offering an activity such as playing card games. D. Review the medication record for an antipsychotic drug

A pt begins taking an atypical antipsychotic med. The nurse must provide informed consent and education about common medication side effects. Which pt education will be most important?

A. Maintain a balanced diet and adequate exercise. B. Be sure that the diet is adequate in salt intake. C. Monitor for any changes in sleep pattern. D. Report any unusual facial movements.

The nurse cares for an adolescent with a history of violence who now exhibits signs of sublimation. Which behavior by the adolescent best represents sublimation?

A. Recently started wetting the bed. B. Joined a competitive boxing team. C. Kicks the dog after being scolded by his dad. D. Starts a student organization to ban violence.

A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which intervention should the nurse include in this client's plan of care?

A. Schedule the client to attend various group activities. B. Reinforce the client's ability to make decisions. C. Encourage the client to identify feelings of anger. D. Provide a structured environment with little stimuli.

The nurse is caring for a mental health client who has been prescribed a benzodiazepine called chlorazapate. Which are the principal indications for this medication? Select all that apply.

Anxiety Insomnia Seizure disorders Alcohol withdrawal

A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan?

Arrives at the clinic neat and appropriate in appearance

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action?

Ask the client who might be available to serve as a witness. Rationale: A living will addresses the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the client who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as a witness. There is no reason to call the HCP.

A client who is on lithium carbonate will be discharged at the end of the week. In reinforcing a discharge teaching plan, the nurse should include which instructions?

Check with the psychiatrist before using any over-the-counter (OTC) medications or prescription medications.

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication?

Dementia

When teaching a client who is being started on imipramine hydrochloride, when should the nurse tell the client that the medication would have the desired effects?

Desired effects do not occur for 2 to 3 weeks of administration.

The nurse is caring for a client who has been prescribed citalopram and checks the client for which signs/symptoms of serotonin syndrome? Select all that apply.

Diarrhea Abdominal Pain Increased blood pressure

The nurse is caring for a client who has been admitted for alcohol abuse and knows that which medications may be prescribed in the treatment of this disorder? Select all that apply.

Diazepam Disulfiram Chlordiazepoxide

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply:

Monitor vital signs Maintain an NPO status Provide a safe environment Address hallucinations therapeutically

A client taking buspirone hydrochloride for 1 month is scheduled for a follow-up appointment. The nurse gathers data from the client and interprets that the medication is effective if the client reports an absence of which sign/symptom?

Palpitations and anxiety

A client is receiving a daily dose of oral fluphenazine. The nurse should reinforce instructions to the client to practice which intervention to minimize common side effects of this medication?

Use hard, sour candy or sugarless gum.

Introjection

is incorporating the values or qualities of an admired person or group into one's own ego structure.

Sublimation

is substituting an unacceptable feeling w/ one that is more socially acceptable.

Repression

is the involuntary exclusion of painful thoughts or memories from one's awareness.