NGN Mental Health Practice B

Client rights with a newly licensed nurse. Which statements should the charge nurse take?

"Clients who are admitted involuntarily maintain the right to give informed consent for procedures." Clients who are admitted involuntarily maintain the right to give informed consent for treatment. They also have the right to give informed consent for procedures.

Nurse is assisting a client who has terminal illness adjust to progressive loss of independence. Client statement indicates acceptance of illness?

"I am going to order a wheelchair for when I am unable to walk" The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates the behavioral response of acceptance.

Providing teaching to the partner of a client who is in a rehab program for alcohol use disorder. Understanding of the teaching?

"I will not take charge of my partner's work responsibilities." The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.

Coping strategies to a client who is experiencing depression related to partner violence. Statement is understanding of teaching?

"I will talk about my feelings with a close friend." Discussing feelings, such as fear and depression, with a support person is an effective coping strategy and can provide the client with emotional support and other resources.

Newly licensed nurse about clients who have depressive disorders. Understanding of teaching?

"I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change.

Birth to a stillborn baby. Which statement should the nurse make?

"I'll stay with you just in case you want to talk." This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings.

Pushing on locked unit door. Statement to make?

"It appears as though you would like to open the door." This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior.

Nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event.

"It is common for people who survived a traumatic event to experience feelings of anxiety" is correct. Clients who have experienced a traumatic event can demonstrate manifestations of severe anxiety and panic attacks, including impulsivity and regression. "A support group might be helpful to you during this time" is correct. The nurse should encourage the client to participate in a support group, which can provide emotional support for a client who has experienced a traumatic event. "You should seek help if you have thoughts of self-harm" is correct. The nurse should inform the client that they should seek help immediately if they experience thoughts of self-harm or suicidal ideation.

Adolescent child's diagnosis of bulimia nervosa. Understanding of illness?

"It is important for our child to have regular dental checkups." For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups are important for a client who has bulimia nervosa.

Cry and "I knew God would punish me and I deserve this horrible sickness!" Response?

"Let's talk about what is upsetting you." The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling.

7.5 mg IV bolus of diazepam for alcohol withdrawal client. Available is diazepam injection 5 mg/ml.

1.5 ml

Four clients in an emergency department. Give informed consent?

A 35-year-old client who has major depressive disorder A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent.

Change-of-shift report for four clients. Assess first?

A client who is experiencing delusions of persecution The presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse should assess this client first.

Nurse is receiving change of shift report for four clients. Which client should the nurse see first?

A client who is taking clozapine and reports a sore throat and chills When using the urgent vs. nonurgent approach to client care, the nurse should determine to first see the client who is taking clozapine and reports a sore throat and chills. Clozapine can cause agranulocytosis, a serious adverse effect that causes neutropenia. The nurse should withhold the medication and notify the provider of these findings.

Medication administration record for a client who is experiencing adverse effects of chlorpromazine. Nurse should administer benztropine to relieve which of the following adverse effects?

Acute dystonia The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.

Caring for four clients. Potential victim of abuse?

An older adult client who is bedbound and has a stage IV pressure ulcer A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.

A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. Anticipated, nonessential, contraindicated

Apply restraints is contraindicated. Physical restraints could increase the client's manifestations of delirium and should be avoided. Urinalysis with culture and sensitivity is anticipated. Initial assessment of a client experiencing delirium should include a review of laboratory results, including urinalysis, to rule out infection. Insert indwelling urinary catheter is contraindicated. Urinary catheters should be inserted only when necessary, such as for a client who is experiencing urinary retention or blockage. Melatonin is anticipated. Melatonin is an over-the-counter supplement used for insomnia and has been found to be beneficial in the prevention and treatment of delirium. MRI of the head is nonessential. MRIs are used to obtain an image of the soft tissue of the brain and are useful in identifying atrophied areas of the brain, such as those found in clients who have Alzheimer's disease. IV fluids is anticipated. The client's oral intake is significantly less than their output and should be supplemented with IV fluids to prevent dehydration.

Discharge teaching for a client who has severe schizoaffective disorder. Which of the following treatment options can offer interdisciplinary services for the client at home?

Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.

Medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. Admission blood alcohol level was 325 mg/dl. Which findings.. alcohol withdrawal?

Blood pressure 154/96 mm Hg Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever.

Mental health unit observes a client who has acute mania hit another client. Which action first?

Call for a team of staff members to help with the situation. The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.

A nurse is caring for a client who has a personality disorder. Improved, no change, declined

Client attempts to bite nursing staff when offered water is an indication the client's condition has declined. The client is exhibiting worsening aggressive and violent behavior by attempting to bite nursing staff members. Client follows instructions of the nurse is an indication the client's condition has improved. The client is exhibiting control over their behavior and is able to follow instructions. Client is silent and glaring at staff is an indication the client's condition has not changed. The client is still exhibiting agitation and nonverbal aggressive behaviors. Client verbalizes precipitating factors to violent outburst is an indication the client's condition has improved. The client is able to verbalize and identify factors that contributed to the violent behavior.

A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. 5 findings that require immediate follow-up

Cognitive awareness is correct. The nurse should evaluate the client for previous and current cognitive status to provide a safe environment. The client's sudden change in cognitive awareness should be reported to the provider because delirium is a medical emergency. Blood pressure is correct. The client's blood pressure is above the expected reference range and should be reported to the provider. Clients who are experiencing delirium might experience an elevated heart rate and blood pressure. Sleep/wake cycle is correct. The client's lack of sleep and restlessness during the night are indications that the client might be experiencing delirium and should be reported to the provider. Confusion and disorientation are often worse at night. I&O is correct. The client's intake of 750 mL is significantly less than the output of 2,500 mL and should be reported to the provider. The imbalance in fluid status, and the resulting alteration in heart rate and blood pressure, could be a cause of the client's delirium. Temperature is correct. A temperature of 38.6° C (101.5° F) on day 3 following right knee arthroplasty is above the expected reference range and should be reported to the provider.

Client who has schizophrenia. Which finding greatest risk for self-directed injury or injuring others?

Command hallucinations A client who has schizophrenia and is experiencing command hallucinations can hear voices telling them to hurt themselves or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self-directed injury or injuring others.

Nurse is performing cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes fo confusion. Which assessment finding supports delirium?

Easily distracted Extreme distractibility is a hallmark manifestation of delirium.

Prevention strategies for partner violence in the community. Secondary prevention?

Establish screening programs to identify at-risk clients. This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take the necessary steps to address individual client needs.

Major depressive disorder, amitriptyline for 1 week. Outcomes expected?

Greater risk of attempting suicide as affect and energy improve The nurse should identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a plan is increased after 1 week of treatment.

Clients who have post-traumatic stress disorder. Interventions to reduce anxiety among the group members?

Guided imagery Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder.

A nurse is caring for a client who has a personality disorder. Anticipated, nonessential, contraindicated

Haloperidol 2 mg IM is anticipated. The client is agitated and displaying manifestations of aggression. Therefore, haloperidol is anticipated. Hold next dose of buspirone is contraindicated. The nurse should plan to administer buspirone to decrease the client's anxiety. Request change of diet to mechanical soft is nonessential. The nurse should plan to maintain the client's diet as prescribed. The client does not exhibit manifestations of difficulty swallowing or chewing. Request prescription for digoxin 1 mg IV bolus STAT is contraindicated. The nurse should identify that the client's heart rate is within the expected reference range. Digoxin is contraindicated for this client. Calmly approach client and state, "You seem agitated. Let's sit quietly and talk about it" is anticipated. The nurse should use therapeutic communication to promote rapport and reduce the client's anxiety.

A nurse is caring for a client who has anorexia nervosa. Improvement in condition?

Heart rate is correct. Clients who have anorexia nervosa usually have bradycardia. The client's heart rate is now within the expected reference range. BMI is correct. Clients who have anorexia nervosa usually have a BMI of less than 17. The client's initial BMI indicates moderate anorexia nervosa while the current BMI indicates mild anorexia nervosa. Potassium is correct. Clients who have anorexia nervosa usually have hypokalemia. The client's potassium level is now within the expected reference range. Skin temperature is correct. Clients who have anorexia nervosa usually have cool skin. After 2 weeks, the client's skin is warm, which indicates improvement. Sodium is correct. Clients who have anorexia nervosa usually have hyponatremia. The client's sodium level is now within the expected reference range. Bowel movement is correct. The client's constipation has improved based on the increased frequency of their bowel movements. BUN is correct. Clients who have anorexia nervosa usually have an increased BUN. The client's BUN level is now within the expected reference range. ... wrong Glucose is incorrect. The client's glucose level has remained within the expected reference range, which does not indicate an improvement in the client's condition. Peripheral edema is incorrect. The client's peripheral edema remains unchanged, which does not indicate an improvement in the client's condition. Blood pressure is incorrect. The client's blood pressure still indicates hypotension, which does not indicate an improvement in the client's condition.

A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. Risk factors for delirium?

Hospital environment is correct. Risk factors for delirium include a change in hospital rooms, such as moving from the ICU to a private room, client's age, vision or hearing impairments, recent surgical procedures, and infection. A change in room location can be disorienting to a client and lead to delirium. Client's age is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, client's age, vision and hearing impairments, recent surgical procedures, and infection. Older adult clients have a higher risk for developing delirium from being in unfamiliar surroundings, such as a hospital. Postoperative is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, client's age, vision or hearing impairments, recent surgical procedures, and infection. Surgical procedures increase a client's risk for delirium due to the effects of anesthesia and pain medications, the risk for infection, and the potential for altered vital signs and fluid and electrolyte balance. Fever is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, client's age, vision or hearing impairments, recent surgical procedures, and infection. Altered vital signs and the risk for infection, as evidenced by fever, increase a client's risk for developing delirium.

Client in abusive relationship and is assisting in the development of a safety plan. First component of a safety plan?

Identify signs of escalation of violence It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the first component of the safety plan because it increases awareness of when danger is imminent and it is time to leave.

Nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which intervention should the nurse include in the plan?

Identify the client's trigger foods The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.

Nurse is teaching partner of client who has bipolar disorder how to identify manifestations of acute mania. Which finding should the client's partner report to the provider?

Inability to sleep During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding.

Client appears withdrawn and fearful. Trusting nurse-client relationship, actions first?

Inform the client that this admission is confidential. According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship.

A nurse is caring for a client who is experiencing delirium. New prescriptions. Complete using list

Initiative IV fluids... Administering acetaminophen

Educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which manifestations for teaching?

Language delay The nurse should identify that language delays are a manifestation of autism spectrum disorder.

A nurse is caring for a client who has a personality disorder. Which actions to take?

Maintain continuous observation of the client while in restraints is correct. The nurse should ensure a staff member remains with the client continuously while the client is in restraints. Conduct debriefing with the client and other staff is correct. The nurse should conduct debriefing with other staff members to indicate the necessity of the intervention and to ensure that quality care was provided. The nurse should conduct a debriefing with the client to discuss their thoughts about what contributed to the intervention and strategies for crisis prevention in the future.

Care for a client who has generalized anxiety disorder. Which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information.

Client has recent diagnosis of biopolar disorder is placed in room with client with severe depression. . Depression says "my roommate never sleeps and keeps me up too" Which action should the nurse take?

Move the client who has bipolar disorder to a private room. Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room.

Nurse is planning care for client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the uhnit, the nurse requests that provider to transfer the client to a unit that is equippted to manage violent behavior. Which ethical principle?

Nonmaleficence It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit.

Discharge for older adult client who attempted suicide. Lives alone and has difficulty performing ADLs. Refferals?

Occupational therapy is correct. An occupational therapist can assist the client to perform ADLs. Meal delivery services is correct. Meal delivery services are necessary due to the client's difficulty performing ADLs. Physical therapy is correct. A physical therapist can assess the client's mobility needs and assist with ADLs. Home health services is correct. Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs.

A nurse is caring for a client who is experiencing delirium. Which actions?

Offer the client warm milk at bedtime is correct. This will help the client to relax and encourage sleep. Maintain a low-stimulation environment for the client is correct. Overstimulation can worsen the client's manifestations of delirium. Maintaining a quiet environment will help the client to relax and encourage sleep. Approach the client from the front and speak slowly is correct. The nurse should approach the client from the front and speak slowly to avoid startling the client.

Dynamics during a counseling session. Boundary issues?

Older children who are responsible for their younger siblings This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.

A nurse is carnig for an older adult client who is experiencing delirium. Which intervention should the nurse include in the client's plan of care?

Permit the client to perform daily rituals to decrease anxiety. The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.

Major depressive disorder and a new prescription for tranylcypromine. Over-the-counter medications potential adverse reaction?

Phenylephrine Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.

Child with conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Priority therapeutic nursing intervention?

Reduce environmental stimuli The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.

Nurse is creating plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which intervention should the nurse include in the plan?

Renew the prescription for the client every 4 hr. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.

A nurse is reviewing a client's medical record. Improvement, no change, or decline

Sleep/wake cycle indicates no change. The client continues to experience confusion and insomnia. Vital signs indicate improvement. All of the client's vital signs are within the expected reference ranges. Daytime orientation indicates improvement. The client is oriented to person, place, and time in the morning, indicating improvement in the client's condition. Glucose level indicates no change. The client's glucose level has remained unchanged and is within the expected reference range. I&O indicates improvement. The client's increased intake from the IV fluids has resolved the fluid imbalance. Pain level indicates improvement. The client's pain rating has dropped from a 5 to a 2 on a scale from 0 to 10, indicating that the client has responded positively to the administration of hydrocodone. Ambulation indicates a decline in condition. The client is not able to ambulate as far as before due to fatigue.

Caring for a group of clients. Which action is ethical justice?

Spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care.

Care for four clients. Delegate to assistive personnel (AP)?

Stay with a client who has anorexia nervosa for 1 hr after mealtimes. Staying with a client who has anorexia nervosa following mealtimes is within the range of function of an AP. APs are allowed to attend to the safety of clients who are stable, and this task does not require assessment or technical skill.

A nurse is caring for a client who has a personality disorder. 6 findings manifestations of the diagnosed personality disorder.

Stealing money from family to cover credit card charges is correct. The nurse should identify that stealing money is an impulsive behavior, which is a manifestation of borderline personality disorder. Anxious if left alone is correct. The nurse should identify that the client's anxiety about being left alone is due to fear of separation, which is a manifestation of borderline personality disorder. Hypersexualization is correct. The nurse should identify that hypersexualization is an impulsive, self-damaging behavior, which is a manifestation of borderline personality disorder. Married multiple times is correct. The nurse should identify that unstable romantic relationships are a manifestation of borderline personality disorder. Incidences of self-injury is correct. The nurse should identify that self-injury is a manifestation of borderline personality disorder. Self-destructive behaviors, such as cutting, are common with this disorder. Physical altercations is correct. The nurse should identify that engaging in physical altercations is a manifestation of borderline personality disorder.

Group of parents who recently experienced the death of a child. Which of the following actions?

Suggest forming a weekly support group for parents who have experienced the death of a child. Support groups are a positive resource in the process of recovery for parents following the death of a child.

A nurse is caring for a client who has a personality disorder. OCD, Dementia, or BPD

Systematic desensitization is an expected therapy for obsessive compulsive disorder. This therapy provides relaxation techniques to address a client's fears. Validation therapy is an expected therapy for dementia. This therapy provides reorientation and validation for clients who experience a misperception of reality. Dialectical behavior therapy is an expected therapy for borderline personality disorder. This therapy provides cognitive and behavioral techniques for clients who are suicidal and have borderline personality disorder. Donepezil 5 mg PO daily is an expected therapy for dementia. This therapy is a cholinesterase inhibitor used to treat cognitive impairment. Fluoxetine 20 mg PO daily is an expected therapy for obsessive compulsive disorder and borderline personality disorder. This therapy is an SSRI used to reduce self-injurious behavior and decreases repetitive behavior.

Child taking methylphenidate. Adverse effect?

Tachycardia The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate.

Assessing client for risk factors for the development of depression. Which factors?

The client has COPD. The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression.

12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?

The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program.

Bulimia nervosa. Which findings?

Tooth erosion A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting.

Interview older adult client. Action to take? Exhibit...

Use a screening tool to evaluate the client for depression. Depression can be underdiagnosed among older adult clients. The nurse should identify several risk factors for depression from the client's data, including having Alzheimer's disease, anxiety, and the loss of a loved one. Manifestations of depression can also be nonspecific for older adult clients and can include weight loss, decreased energy levels, and difficulty sleeping.

Lab results for a client who has schizophrenia and is taking clozapine. Contraindication for receiving clozapine?

WBC count 2,500/mm3 Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.

A nurse is caring for a client who has a personality disorder. Complete using the lists of options

violent behavior... increased agitation