PN MENTAL HEALTH ONLINE PRACTICE 2017 A

A nurse is preparing to administer haloperidol 3 mg IM to a client. Available is haloperidol solution 5 mg/mL. How many mL should the nurse plan to administer?

0.6 mL

A nurse is caring fro a client who has major depressive disorder (MMD). The client states, "I have nothing to live for anymore. I just can't go on." Which of the following responses should the nurse make? A. "Are you thinking about ending your life?" B. "Don't you think it's best to let your family know how you feel?" C. "I'm sure you can't mean that. You have everything to live for." D. "I know how you feel right now. Everything will be okay."

A. "Are you thinking about ending your life?"

A nurse is collecting data from a newly admitted client. Which of the following questions should the nurse include to gather psychosocial information? A. "Do you have a hobby that you enjoy?" B. "What is the date and where are you living?" C. "How are an apple and an orange alike?" D. "Can you take this pencil and put it in the cup?"

A. "Do you have a hobby that you enjoy?"

A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statements should the nurse include in the teaching? A. "The voices you have been hearing should decrease." B. "You will likely have more energy while on this medication." C. "You should now be able to spend more time in the sun." D. "Call your provider immediately if you develop a dry mouth."

A. "The voices you have been hearing should decrease." This medication targets positive symptoms of schizophrenia

A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When the news report about military action comes on the television, the client says to the nurse, "My youngest child died 6 moths ago while serving in the military." Which of the following responses should the nurse make? (Select all) A. "This must be a very difficult time for you." B. "Your child's death must be a terrible loss." C. "It's just awful what is going on in the world." D. "You need to focus on getting better." E. "Tell me something you remember about your child."

A. "This must be a very difficult time for you." B. "Your child's death must be a terrible loss." E. "Tell me something you remember about your child."

A nurse is reinforcing teaching with a newly admitted client who has generalized anxiety disorder. Which of the following statements should the nurse make? A. "We will demonstrate for you how to use relaxation techniques." B. "Someone will be here to work with you when you experience flashbacks." C. "Aversion therapy will be used to decrease your anxiety level." D. "Response prevention therapy will help you control your impulses."

A. "We will demonstrate for you how to use relaxation techniques."

A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse uses as an example to identify negligence? A. A nurse dose not notify the provider of a change in condition for a client who has schizophrenia B. A nurse delegates an assistive personnel to sit with a client who has bulimia nervosa during mealtimes C. A nurse administers an anti-anxiety medication to a restless client who has given implied consent D. A nurse does not document completion of an incident report about a recent fall in the client's medical record

A. A nurse dose not notify the provider of a change in condition for a client who has schizophrenia

A nurse is assisting with the admission of a client who has schizophrenia. Which of the following actions should the nurse take first? A. Conduct an abnormal involuntary movement scale test B. Discuss behavioral expectations with the client C. Orient the client to unit rotinues D. Encourage the client to attend group art sessions

A. Conduct an abnormal involuntary movement scale test The first thing the nurse should do is collect as much data as possible on the patient.

A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include in the plan to address limit setting? A. Establish an explain consequences for the client's behaviors B. Teach the client to use reaction formation for behavior control C. recommend the client attend assertiveness training D. Encourage the client to increase socialization

A. Establish an explain consequences for the client's behaviors

A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indicator of the client's use of this substance? A. Hypertension B. Drowsiness C. Bradycardia D. Constricted pupils

A. Hypertension Cocaine is a central nervous system stimulant - this is an expected findings

A nurse is organizing care for a group of clients. According to Maslow's hierarchy of needs, which of the following interventions should the nurse plan to perform first? A. Offer finger foods to a client who is in the manic phase of bipolar disorder B. Document the affect of a client who had light therapy for seasonal affective disorder 2 days ago C. Assist a client who has a depressive disorder with decision making regarding group activities D. Reinforce teaching about a new prescription of clozapine with a client who has schizophrenia

A. Offer finger foods to a client who is in the manic phase of bipolar disorder

A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few moments later, the client cheerfully states, "Now, here is my favorite social worker!" the nurse should identify the client is using which of the following defense mechanisms? A. Reaction formation B. Dissociation C. Denial D. Projection

A. Reaction formation The client is unable to process unacceptable feelings or behavior and expresses the opposite to decrease anxiety

A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse take first? A. Remove harmful objects from the client's room B. Decrease the client's environmental stimuli C. Administer an anti-psychotic medication to the client D. Provide physical activities for the client

A. Remove harmful objects from the client's room

A nurse is caring for a client in a day treatment program. Which of the following actions should the nurse take? Exhibit 1: History and Physcial Subjective: Client states, "My stomach hurts"; "I feel more sad and alone every day." Client's adult child states to the nurse upon dropping the client off today, "I've been meaning to tell you, I started giving my dad St. John's wort several weeks ago to improve his mood." Objective: Episodes of speech in-coherency, rapid mood swings, 3 episodes of vomiting in last 40 min. Moderate Alzheimer's disease Exhibit 2: Providers Prescriptions Fluoxetine 20 mg PO daily Trazodone 50 mg PO daily at bedtime Omeprazole 20 mg PO daily Exhibit 3: Diagnostic Results Blood pressure - 172/94 mm Hg Temperature 38.2 (100.8) Pulse rate 110/min Respiratory rate 24/min A. Request transport for the client to an emergency department B. Place a hypothermia blanket on the client C. Discontinue the client's fluoxetine therapy immediately D. Implement droplet precautions for this client

A. Request transport for the client to an emergency department The client has manifestations of serotonin syndrome - life threatening and is causes by an over activation of the central serotonin receptors. Related to interactions with an SSRI and trazodone along with St. John's wort.

A nurse is assisting with discharge planning for a client who needs a day treatment center and has limited community and financial support. Which of the following referrals should the nurse recommend for inclusion in the client's discharge plan? A. Social worker B. Recreational therapist C. Psychologist D. Occupational therapist

A. Social worker Social workers can assist clients with building a support structure to help promote and preserve mental health, including contacting day treatment centers and arranging for financial and other community resources

A nurse is reinforcing discharge teaching with a client who has a new prescription for alprazolam. Which of the following instructions is the priority for the nurse to include? A. "Avoid drinking beverages that contain caffeine." B. "Do not drive until your reaction to the medication is determined." C. "Avoid taking naps in the daytieme." D. "Take this medication with a light snack."

B. "Do not drive until your reaction to the medication is determined."

A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions? A. "For the first step of my therapy, I will look at pictures of cars." B. "I will snap a rubber band on my wrist when I feel anxious about riding in a car." C. "My therapist will be with me while we ride in the car together." D. "I will ride in a car for several hours at a time."

B. "I will snap a rubber band on my wrist when I feel anxious about riding in a car."

A nurse on an inpatient unit is assisting with a group therapy session. During the session, a client begins to shout, using aggressive language. Which of the following statements should the nurse make to the client? A. "Why do you feel the need to speak this way to others in the group? B. "When you raise your voice, it makes me feel uncomfortable and unsafe." C. "You are frightening others in the group when you show your anger." D. "Why are you attending group therapy but not respecting the feelings of others?"

B. "When you raise your voice, it makes me feel uncomfortable and unsafe."

A nurse is collecting data from a client who has bulimia nervosa. Which of the following manifestations should the nurse expect? A. Amenorrhea B. Dental caries C. Lanugo D. Yellow skin

B. Dental caries Dental caries is tooth decay - this is d/t the increased acid in the stomach that is found in the vomit

A nurse is caring for an adult client who has visible injuries as a result of intimate partner violence. Which of the following actions should the nurse take? A. Insist that the client reports the incident to the authorities before beginning treatment B. Encourage the client to develop a safety plan C. Recommend that the partner remain in the room during the interview with the client D. Advise the client to obtain an order of protection from the court

B. Encourage the client to develop a safety plan

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following manifestatiosn should the nurse expect? A. Increased yawning B. Bradycardia C. Hypersomnia D. Diaphoresis

D. Diaphoresis

A nurse in a mental health facility is caring for a client who has dementia. The client's agitation is increasing. Which of the following actions should the nurse take first? A. Move the client to a private room B. Offer diversionary activities C. Administer haloperidol D. Apply wrist restraints

B. Offer diversionary activities

A nurse is collecting data from a client who has bipolar disorder and a history of mania. Which of the following findings should the nurse identify as an indication that the client is relapsing? A. Weight gain B. Pressured speech C. Ritualistic behavior D. Anhedonia

B. Pressured speech Rapid or pressured speech, proactive behavior, and insomnia are indications of potential relapse

A nurse is reinforcing teaching with the family of a client who has histrionic personality disorder. Which of the following high-risk behaviors should the nurse instruct the family to observe for in the client? A. Self-mutilation through cutting B. Seductive behavior C. Repeated physical aggression D. Reckless driving

B. Seductive behavior

A nurse in a provider's office is collecting data from an older adult client whose adult child reports that she "seems confused and can't seem to remember much." Which of the following findings should lead the nurse to suspect delirium? A. The client's confusion worsens during times of stress B. The client's level of consciousness changes during the interview C. The client's confusion improves in the evening D. The client becomes irritable during the interview

B. The client's level of consciousness changes during the interview

A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client's confidentality? A. The nurse documents client statements word-for-word in the client's medical record B. The nurse places the client's diagnosis on the white board in the client's room C. The nurse faxes the client's known allergies to the pharamacy D. The nurse reports threats the client made to harm her partner to the provider

B. The nurse places the client's diagnosis on the white board in the client's room

A nurse is collecting data from a client who is having difficulty coping with the death of his child. Which of the following questions by the nurse is the priority? A. "What events led you to seek help?" B. "Who can you turn to for support?" C. "Do you thin about harming yourself?" D. "Which activities help you to have a better day?"

C. "Do you thin about harming yourself?"

A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statements should the nurse make to gather information about the client's ability to think abstractly? A. "Subtract 7 from 100 and then continue subtracting 7 from each answer." B. "What do you think about when you are angry?" C. "How is an orange similar to an apple." D. "Tell me about a vacation you took when you were a child growing up."

C. "How is an orange similar to an apple."

A nurse is caring for a client who gave birth to a stillborn fetus one week ago. She states to the nurse, "I am so angry that my doctor didn't take better care of me and my baby." Which of the following responses should the nurse make? A. "You will start feeling better in a few weeks." B. "You should begin to accept what happened so you can work through your loss." C. "It is important to share what you are feeling even if it is anger." D. "Exhibiting anger toward others will only make you feel guilty later on

C. "It is important to share what you are feeling even if it is anger."

A nurse is assisting with screening a group of clients for major depressive disorder (MMD). The nurse should identify that which of the following clients is at an increased risk for the development of MDD? A. A client who is newly employed B. A client who abstains from alcohol C. A client who just gave birth D. A client who has been married for 15 years

C. A client who just gave birth

A nurse on a mental health unit is prioritizing care for a group of clients. Which of the following actions should the nurse take first? A. Reinforce teaching about the importance of participating in group therapy for a client who has major depressive disorder B. Administer lamotrigine to a client who has bipolar disorder and is pacing in the hallway C. Administer haloperidol to a client who has schizophrenia and is yelling at other clients D. Reinforce teaching on assertive behaviors for a client who has dependent personality disorder and is asking the nurse for help

C. Administer haloperidol to a client who has schizophrenia and is yelling at other clients

A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findings is referred to as a negative symptom of schizophrenia? A. Delusions B. Echolaila C. Apathy D. Paranoia

C. Apathy Negative symptoms of schizophrenia are deficits in the client's ability to experience emotion

A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? A. Call for assistance to place the client in restraints B. Administer a sedative to the client C. Determine the client's intentions D. Place the client into the assigned seclusion room

C. Determine the client's intentions

A nurse is collecting data from a client who has major depressive disorders. Which of the following findings is the priority for the nurse to report to the provider? A. Inability to make decisions B. Anhedonia C. Feelings of hopelessness D. Fatigue

C. Feelings of hopelessness

A nurse at an outpatient mental health clinic is assisting with a group therapy session. One of the participants is having difficulty saying seated and states loudly to the therapist, "I know more than you do about the people in this room!" The nurse should identify that which of the following findings is the likely explanation for the client's behavior? A. Somatization B. Opioid intoxication C. Hypomania D. Maijuana intoxication

C. Hypomania

A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder and continually washes her hands. Which of the following interventions should the nurse include? A. Turn off water if the client washers her hands more than once B. Do not allow the client to use a private restroom C. Schedule times for the client to wash her hands during the day D. Explain that unit privileges will be taken away if excessive handwashing continues

C. Schedule times for the client to wash her hands during the day

A nurse in a long-term care center is caring for an adult client who has Alzheimer's disease and whose partner died several years ago. The client appears upset and asks the nurse when his partner will visit again. The nurse states, "It seems like you are feeling lonely. Let's take a walk outside and talk." Which of the following communication strategies is the nurse using? A. Reminiscence therapy B. Feedback C. Validation therapy D. Reflecting

C. Validation therapy

A nurse is preparing to administer clozapine for the first time to a client who has schizophrenia. The nurse explains the therapeutic and adverse effects of the medication to the client prior to administration. Which of the following ethical concepts is the nurse demonstrating? A. Autonomy B. Justice C. Veracity D. Confidentiality

C. Veracity Veracity is the duty to tell the truth - the nurse should uphold this ethical principle when administering a new medication to a client by explaining the therapeutic effects as well as adverse effects

A nurse is assisting with the planning of an interdisciplinary care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interdisciplinary treatment team should the nurse include? A. Occupational therapist B. Pharmacist C. Nurse researcher D. Dietitian

D. Dietitian

A nurse is caring for a client who takes nalresone for the treatment of alcohol use disorder. The nurse should identify that which of the following client statements indicates the medication is effective? A. "Naltrexone calms my nerves." B. "I get flushed when I drink alcohol while taking nalrexone." C. Naltrexone decreases my fine hand tremors." D. "I drink less alcohol in a day while taking naltreone."

D. "I drink less alcohol in a day while taking naltreone." This medication decreases the craving for alcohol and decreases the pleasurable effects from alcohol

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and is to start therapy with buspirone. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "This medication can cause dependence." B. "I'll take an extra dose of my medication when I start to feel anxious." C. "It's important for me to take my medication 30 minutes before bedtime." D. "I should expect some improvement of my symptoms in about 10 days."

D. "I should expect some improvement of my symptoms in about 10 days."

A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statements indicates an understanding of the information? A. "I can expect my cigarette craving to go away within 7 to 10 days." B. "I will likely feel like my heart is racing even when I'm resting." C. "I should increase my intake of calories because of the expected weight loss." D. "I will probably feel irritable within 24 hours of my last cigarette."

D. "I will probably feel irritable within 24 hours of my last cigarette."

A nurse on an inpatient unit is collecting data from a group of clients. Which of the following findings should the nurse report to the provider? A. A client who has schizophrenia and is using neologisms B. A client who has bipolar disorder and is experiencing flight of ideas C. A client who has depression and avoids making eye contact D. A client who has borderline personality disorder and is pacing restlessly

D. A client who has borderline personality disorder and is pacing restlessly This patient is at increased risk for violence towards themselves and others - this should be reported

A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania. Which of the following interventions should the nurse include to improve the nutritional status of the client? A. Weigh the client at the same time every other day B. Encourage the client to attend communal meals C. Request that the client keep a detailed food and beverage diary each day D. Have the client's favorite snacks available at all times

D. Have the client's favorite snacks available at all times The client is often too busy to sit and consume meals during the manic phase of bipolar disorder - which makes snacks easier and more likely to consume

A nurse is developing counter-transference toward a client during the working phase of the nurse-client relationship. To correct the situation, which of the following actions should the nurse take? A. Tell the client how to change her behaviors B. Talk tot the client about developing feelings C. Ask to be reassigned to a different client D. Identify personal response to the client

D. Identify personal response to the client Counter-transference is an emotional response toward the client by the nurse - this might be related to the nurse's past unresolved feelings or relationships.

A nurse is reinforcing teaching with the parent of a child who has ADHD and is exhibiting disruptive behaviors at home. Which of the following actions should the nurse instruct the parent to take? A. Avoid enforcing a strict schedule for the child at home B. Use biofeedback with the child C. Give the child a PRN dose of methylphenidate D. Initiate a point system for the child

D. Initiate a point system for the child

A nurse is collecting data from a newly admitted client who has anorexia nervosa. Which of the following manifestations should the nurse expect? A. Tachycardia B. BMI of 22 C. Hypertension D. Peripheral edema

D. Peripheral edema This is an expected finding d/t hypoalbuminemia and weight loss

A nurse is collecting data from a client who has paranoid personally disorder. Which of the following manifestations should the nurse expect? A. Preoccupied with details B. Uses attention-seeking behaviors C. Exploitative of others D. Projects blame onto others

D. Projects blame onto others

A nurse is attempting to establish a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? A. Summarize the goals achieved in the relationship B. Plan for the initial interaction with the client C. Establish the parameters of the relationship D. Promote the development of problem-solving skills

D. Promote the development of problem-solving skills The nurse should promote the development of problem-solving skills, promote behavioral change, and evaluate the client's progress during the working phase of the nurse-client relationship

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? A. Hypo-tension B. Bradycardia C. Hypothermia D. Pupillary dilation

D. Pupillary dilation When clients begin the withdrawal process, the pupils relax, causing dilation to occur. This manifestation will gradually diminish over 5 to 10 days