The Practice of Mental Health/Psychiatric Nursing

33. Which statement best describes the practice of psychiatric nursing? 1. Helps people with present or potential mental health problems 2. Ensures clients' legal and ethical rights by being a client advocate 3. Focuses interpersonal skills on people with physical or emotional problems 4. Acts in a therapeutic way with people who are diagnosed as having a mental disorder

1 An important aspect of the role of the psychiatric nurse is primary, secondary, and tertiary interventions to promote emotional equilibrium.

51. A nurse educator is leading a class on supporting middle-aged adults who are experiencing midlife crisis. What should the nurse include as the most significant factor in the development of this type of crisis? 1. The perception of their life situation 2. Many role changes that alter their experiences at this time 3. The anticipation of negative changes associated with old age 4. Lack of support from family members who are busy with their own lives

1 The most significant factor in either precipitating or avoiding a crisis is not the events but how the individual perceives them.

86. A client has been receiving escitalopram (Lexapro) for treatment of a major depressive episode. On the fifth day of therapy the client refuses the medication stating, "It doesn't help, so what's the use of taking it?" What is the nurse's best response? 1. "Sometimes it takes 1 to 4 weeks to see an improvement." 2. "It takes 6 to 8 weeks for this medication to have an effect." 3. "I'll talk to your health care provider about increasing the dose. That may help." 4. "You should have felt a response by now. I'll notify your health care provider immediately."

1 It usually takes 1 to 4 weeks to attain a therapeutic blood level of this monoamine oxidase inhibitor (MAOI).

58. A child in the first grade is murdered, and counseling is planned for the other children in the school. What should a nurse identify first before assessing a child's response to a crisis? 1. Developmental level of the child 2. Quality of the child's peer relationships 3. Child's perception of the crisis situation 4. Child's communication patterns with family members

1 Developmental level is essential to understanding a child's response to a crisis situation; the variety of coping abilities usually increases as the child progresses through the stages of growth and development

82. A primary nurse observes that a client has become jaundiced after 2 weeks of antipsychotic drug therapy. The primary nurse continues to administer the antipsychotic until the health care provider can be consulted. What does the nurse manager conclude concerning this situation? 1. Jaundice is sufficient reason to discontinue the antipsychotic. 2. The blood level of antipsychotics must be maintained once established. 3. Jaundice is a benign side effect of antipsychotics that has little significance. 4. The prescribed dose for the antipsychotic should have been reduced by the nurse.

1 Liver damage is a well-documented toxic side effect of antipsychotics. By continuing to administer the drug, the nurse failed to use professional knowledge in the performance of responsibilities as outlined in the Nurse Practice Act.

87. A client is receiving doxepin (Silenor). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client? 1. Mydriasis 2. Dry mouth 3. Constipation 4. Urinary retention

1 Mydriatic action causes dilated pupils, which can precipitate an acute attack of glaucoma, resulting in blindness.

64. A nurse is teaching clients about dietary restrictions when taking a monoamine oxidase inhibitor (MAOI). What response does the nurse tell them to anticipate if they do not follow these restrictions? 1. Occipital headaches 2. Generalized urticaria 3. Severe muscle spasms 4. Sudden drop in blood pressure

1 Occipital headaches are the beginning of a hypertensive crisis that results from excessive tyramine.

92. Olanzapine (Zyprexa) is prescribed for a client with bipolar disorder, manic episode. What cautionary advice should the nurse give the client? 1. Sit up slowly. 2. Report double vision. 3. Expect increased salivation. 4. Take the medication on an empty stomach

1 Olanzapine (Zyprexa), a thienobenzodiazepine, can cause orthostatic hypotension.

42. A nurse encourages a client to join a self-help group after being discharged from a mental health facility. What is the purpose of having people work in a group? 1. Support 2. Confrontation 3. Psychotherapy 4. Self-awareness

1 Self-help group members share similar experiences and can provide valuable understanding and support to each other.

85. A monoamine oxidase inhibitor (MAOI) is prescribed. What should the nurse include in the teaching plan about what to avoid when taking this drug? 1. Ingesting aged cheeses 2. Prolonged exposure to the sun 3. Engaging in active physical exercise 4. Over-the-counter antihistamine drugs

1 The monoamine oxidase inhibitors can cause a hypertensive crisis if food or beverages that are high in tyramine are ingested.

39. What is the most important tool a nurse brings to the therapeutic nurse-client relationship? 1. Oneself and a desire to help 2. Knowledge of psychopathology 3. Advanced communication skills 4. Years of experience in psychiatric nursing

1 The nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship.

49. A client is diagnosed with a borderline personality disorder. What is a realistic initial intervention for this client? 1. Establish clear boundaries. 2. Explore job possibilities with the nurse. 3. Initiate discussion of feelings of being victimized. 4. Spend one hour twice a day discussing problems with the nurse.

1 Individuals with a borderline personality disorder are impulsive and have difficulty identifying and respecting boundaries in relation to others

31. A health care provider orders "Restraints prn" for a client who has a history of violent behavior. What is the nurse's responsibility concerning this order? 1. Ask that the order indicate the type of restraint. 2. Recognize that prn orders for restraints are unacceptable. 3. Implement the restraint order when the client begins to act out. 4. Ensure that the entire staff is aware of the order for the restraint.

2 New orders must be written each time a client requires restraints. When a client is acting out, the nurse may use restraints or a seclusion room and then obtain the necessary order.

47. A client with the diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next? 1. Continue the unit's activities as if nothing happened. 2. Arrange a unit meeting to discuss what just happened. 3. Refocus clients' negative comments to more positive topics. 4. Have a private talk with the clients who cried or started to pace.

2 This provides an opportunity for the other clients to voice and share feelings and to identify and separate real from imaginary fears; an open expression of feelings allows the nurse to address clients' fears and provide reassurance.

37. A male nurse is caring for a client. The client states, "You know, I've never had a male nurse before." What is the nurse's best reply? 1. "Does it bother you to have a male nurse?" 2. "How do you feel about having a male nurse?" 3. "There aren't many male nurses. We are a minority." 4. "You sound upset. I will get a female nurse to care for you."

2 This statement encourages the client to express and explore feelings; also, it is open and nonjudgmental

56. An extremely anxious client enters a crisis center and asks a nurse for help. Which response best reflects the nurse's role in crisis intervention? 1. "Tell me what you have done to help yourself." 2. "I will be here for you to help you figure things out." 3. "I understand that in the past you have had problems." 4. "Tell me about the things that are bothering you the most."

2 Clients in crisis need assistance with coping; the nurse must be involved with problem solving.

75. A health care provider prescribes haloperidol (Haldol) for a client. What should the nurse teach the client to avoid while taking this medication? 1. Driving at night 2. Staying in the sun 3. Ingesting aged cheeses 4. Taking medications containing aspirin

2 Haloperidol (Haldol) causes photosensitivity. Severe sunburn can occur on exposure to the sun.

61. A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, a nurse expresses disgust that the woman returns to the same situation. What is the nurse manager's best response? 1. "She must not have the financial resources to leave her husband." 2. "Most woman attempt to leave about six times before they are able to do so." 3. "There is nothing the staff can do because people are free to choose their own life." 4. "These women should be told how foolish they are to remain in their current situation."

2 Nurses who work with clients who are victims of partner abuse need to be supportive and patient. It takes time and several attempts for most victims to be able to leave abusive relationships.

46. A 44-year-old client is unable to function since her husband asked for a divorce 2 weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis reflects this situation? 1. Social 2. Situational 3. Maturational 4. Developmental

2 Situational crises involve an unanticipated loss, such as a divorce, that is threatening to the client.

59. What is an initial client objective in relation to anger management? 1. Expressing remorse over aggressive actions 2. Taking responsibility for the hostile behavior 3. Developing alternative methods to release feelings 4. Teaching others how to avoid triggering the angry behavior

2 Before progress can be made in treating anger, clients need to take responsibility for their behavior. As long as they blame others, they will not be motivated to change.

70. Chlordiazepoxide (Librium) 100 mg PO per hour is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client had 300 mg in 3 hours and is still displaying acute alcohol withdrawal symptoms. What is the next nursing action? 1. Inform the client that the limit of chlordiazepoxide has been reached. 2. Administer chlordiazepoxide as indicated by the client's CIWA score. 3. Request a prescription for another medication to replace the chlordiazepoxide. 4. Inform the health care provider that the maximum dose of chlordiazepoxide has been reached.

2 Clients in acute withdrawal from alcohol should be medicated based on withdrawal symptoms, not medication dosage. The use of the CIWA for alcohol scale promotes assessment and evaluation of the client experiencing withdrawal.

52. What is the priority goal when planning care for a client in crisis? 1. Referring the client for occupational therapy 2. Restoring the client's psychologic equilibrium 3. Scheduling the client for follow-up counseling 4. Having the client gain insight into the problem

2 Crisis intervention is short-term therapy with the major goal of restoring clients to their precrisis state.

68. What medication should the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines? 1. Lithium 2. Flumazenil 3. Methadone 4. ChlorproMAZINE

2 Flumazenil (Romazicon) is the drug of choice in the management of overdose when a benzodiazepine is the only agent ingested by a client not at risk for seizure activity. This medication competitively inhibits activity at benzodiazepine recognition sites on GABA/benzodiazepine receptor complexes.

63. A depressed client has been prescribed a tricyclic antidepressant. How long should the nurse inform the client it will take before noticing a significant change in the depression? 1. 4 to 6 days 2. 2 to 4 weeks 3. 5 to 6 weeks 4. 12 to 16 hours

2 It takes 2 to 4 weeks for the drug to reach a therapeutic blood level.

45. At a group therapy session a client tearfully tells the other members, "I just lost my job this week." What is the nurse leader's most appropriate response? 1. Ask the client to consider the reasons this may have occurred. 2. Quietly observe how the group responds to the client's statement. 3. Gently suggest that the client check the help-wanted advertisements in the local paper. 4. Request that the group help the client reflect on how the dismissal may have been prevented.

2 The leader should not intervene at this point; the client addressed the statement to the group, and the group response should be fostered.

69. A nurse is caring for a client who abruptly withdrew from barbiturate use. What should the nurse anticipate that the client may experience? 1. Ataxia 2. Seizures 3. Diarrhea 4. Urticaria

2 This is a serious side effect that may occur with abrupt withdrawal from barbiturates.

38. A nurse reminds a client that it is time for group therapy. The client responds by yelling at the nurse, "You are always telling me what to do, just like my father!" What defense mechanism is the client using? 1. Regression 2. Transference 3. Reaction formation 4. Cognitive distortion

2 With transference a client assigns to someone the feelings and attitudes originally associated with an important significant other

88. A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the primary nurse, "Which of the prescribed medications will be most helpful for reducing psychotic signs and symptoms?" What should the nurse respond? 1. Citalopram (Celexa) 2. Ziprasidone (Geodon) 3. Benztropine (Cogentin) 4. Acetaminophen with hydrocodone (Lortab)

2 Ziprasidone (Geodon) is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin.

80. A nurse is educating a client who is taking clozapine (Clozaril) for paranoid schizophrenia. What should the nurse emphasize about the side effects of clozapine? 1. Risk for falls 2. Inability to sit still 3. Increase in temperature 4. Dizziness upon standing

3 Clozapine (Clozaril) may cause agranulocytosis, which can result in acquiring an infection.

78. A client with type 1 diabetes is diagnosed with a psychosis and is to receive haloperidol (Haldol). Which response should a nurse anticipate with this drug combination? 1. Depressed respirations 2. Intensified action of both drugs 3. Decreased control of the diabetes 4. Increased danger of extrapyramidal side effects

3 Haloperidol (Haldol) alters the effectiveness of exogenous insulin, and the combination of haloperidol and insulin must be used with caution.

79. In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), or benztropine (Cogentin) often prescribed? 1. Anxiolytics 2. Barbiturates 3. Antipsychotics 4. Antidepressants

3 These medications are used to control the extrapyramidal (parkinsonism-like) symptoms that often develop as a side effect of antipsychotic therapy.

50. A nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time someone says the word "mother" or if the mother's name is mentioned. What does the nurse conclude about this behavior? 1. It is an expected response. 2. Most people cry when their mother dies. 3. The co-worker may need help with grieving. 4. The co-worker was extremely attached to the mothe

3 Crying is a release, but the individual should have developed effective coping mechanisms by this time. The co-worker may need help with the grieving process.

65. A client is receiving lithium. What is an important nursing intervention while this medication is being administered? 1. Restrict the client's daily sodium intake. 2. Test the client's urine specific gravity weekly. 3. Monitor the client's drug blood level regularly. 4. Withhold the client's other medications for several days.

3 Lithium alters sodium transport in nerve and muscle cells and causes a shift toward intraneuronal metabolism of catecholamines. Since the range between therapeutic and toxic levels is very small, the client's serum lithium level should be monitored closely.

89. A client with a psychosis is receiving olanzapine (Zydis). What is important for a nurse to consider when administering this drug? 1. It can be given intramuscularly. 2. A special tyramine-free diet is required. 3. It dissolves instantly after oral administration. 4. An empty stomach increases its effectiveness.

3 Olanzapine (Zyprexa, Zydis) is an oral disintegrating tablet, which will instantly dissolve on contact with moisture.

35. What is the most difficult initial task when developing a nurse-client relationship? 1. Remaining therapeutic and professional 2. Being able to understand and accept a client's behavior 3. Developing an awareness of self and the professional role in the relationship 4. Accepting responsibility for identifying and evaluating the real needs of a client

3 The nurse's major tool in mental health nursing is the therapeutic use of self. Mental health nurses must learn to identify their own feelings and understand how they affect the situation.

77. A client with depression is to receive fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug? 1. It must be given with milk and crackers to avoid hyperacidity and discomfort. 2. Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis. 3. Blood levels may not be sufficient to cause noticeable improvement for 2 to 4 weeks. 4. Blood levels should be obtained weekly for 3 months to monitor for appropriate levels.

3 This drug does not produce an immediate effect; nursing measures must be continued to decrease the risk for suicide

60. A nurse leads an assertiveness training program for a group of clients. Which client statement demonstrates that the treatment has been effective? 1. "I know I should put the needs of others before mine." 2. "I won't stand for it, so I told my boss he's a jerk and to get off my back." 3. "It annoys me when people call me 'Dearie,' so I told him not to do it anymore." 4. "It is easier for me to agree up front and then just do enough so that no one notices."

3 This is an assertive statement; it clearly states what the problem is and sets limits on undesired behavior without being demeaning.

91. A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, "Sometimes I forget to take the Cogentin." What should the nurse teach the client to do if this happens again? 1. Use 2 pills at the next regularly scheduled dose. 2. Notify the health care provider about the missed dose immediately. 3. Take a dose as soon as possible, up to 2 hours before the next dose. 4. Skip the dose, and then take the next regularly scheduled dose 2 hours early

3 This is the advised intervention when a dose is missed; interruption of the medication may precipitate signs of withdrawal such as anxiety and tachycardia.

84. A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect should a nurse monitor the client? 1. Torticollis 2. Oculogyric crisis 3. Tardive dyskinesia 4. Pseudoparkinsonism

3 This occurs as a late and persistent extrapyramidal complication of long-term antipsychotic therapy. It is most often manifested by abnormal movements of the lips, tongue, and mouth.

44. During a group meeting a client tells everyone, "I am afraid of my impending discharge from the hospital." What is the most appropriate response by the nurse facilitator? 1. "You ought to be happy that you're leaving." 2. "Maybe you're not ready to be discharged yet." 3. "Maybe others in the group have similar feelings that they would share." 4. "How many in the group feel that this member is ready to be discharged?"

3 This permits the client to see that personal feelings are not unique but are shared by others.

96. A client with mild Alzheimer disease has been taking galantamine (Razadyne), and the health care provider prescribes paroxetine (Paxil) for depression. For what effect should a nurse assess the client when these medications are taken concurrently? 1. Allergic 2. Dystonic 3. Additive 4. Extrapyramidal

3 When paroxetine (Paxil) and galantamine (Razadyne) are taken together, they potentiate the action of each other

62. What is the most important information a nurse should teach to prevent relapse in a client with a psychiatric illness? 1. Develop close support systems 2. Create a stress-free environment 3. Refrain from activities that cause anxiety 4. Follow the prescribed medication regimen

4 This is important because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse.

32. A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse's response? 1. The appointment of a surrogate decision maker is unnecessary. 2. A client is permitted to dictate what treatments will be given during future hospitalizations. 3. The need for involuntary admissions is eliminated when a client is a threat to self or others. 4. A client is allowed to consent or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs.

4 The purpose of a PAD is to allow psychiatric clients the opportunity to provide input into future treatment decisions.

73. A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What intervention is important during the 6-week course of treatment? 1. Provision of tyramine-free meals 2. Avoidance of exposure to the sun 3. Maintenance of a steady sodium intake 4. Elimination of benzodiazepines for nighttime sedation

4 The use of these drugs can raise the seizure threshold, which is counterproductive.

72. A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks? 1. Lithium 2. Diazepam 3. Fluvoxamine 4. Fluphenazine

4 This medication can be given IM every 2 to 3 weeks for clients who are unreliable in taking oral medications; it allows them to live in the community while keeping the disorder under control.

43. As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because "I have nothing to talk about." What is the best response by the nurse? 1. "Maybe tomorrow you will feel more like talking." 2. "Could you start off by talking about your family?" 3. "A person like you has a great deal to offer the group." 4. "You feel you will not be accepted unless you have something to say?"

4 This reflective statement allows the client to either validate or correct the nurse.

67. A nurse administers an antipsychotic to a client. For which common manageable side effect should the nurse assess the client? 1. Jaundice 2. Melanocytosis 3. Drooping eyelids 4. Unintentional tremors

4 Unintentional tremors are one of the extrapyramidal side effects of the antipsychotics and are considered common and manageable.

74. Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when administering this medication? 1. Tell the client that barbiturates and steroids will not be prescribed. 2. Warn the client not to eat cheese, fermenting products, and chicken liver. 3. Monitor the client for increased tolerance and report if the dosage is no longer effective. 4. Have the client checked for increased intraocular pressure and teach about symptoms of glaucoma.

4 The development of glaucoma is one of the side effects of imipramine (Tofranil), and the client should be taught the symptoms.

81. A nurse is teaching clients in a medication education group about side effects of medications. Which drug will cause a heightened skin reaction to sunlight? 1. Lithium 2. Sertraline 3. Methylphenidate 4. ChlorproMAZINE

4 Clients taking chlorproMAZINE should be instructed to stay out of the sun. Photosensitivity makes the skin more susceptible to burning

40. A Latino client with schizophrenia is admitted to a mental health unit in an aggravated and disheveled state after failing to take prescribed medications for the last 5 days. When developing a plan of care that incorporates the client's cultural background, the nurse gives priority to: 1. socioeconomic considerations regarding hospitalization. 2. the meaning and attention the client places on the future. 3. the client's need to control care to ensure desired outcomes. 4. inclusion of the family in the plan of care with the client's permission.

4 In the Latino culture, usually there is a strong family bond, and the support of the family is essential during problematic times.

48. A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting out behavior? 1. Being assertive 2. Responding early 3. Providing choices 4. Teaching relaxation

4 Once the client is agitated, trying to teach any information is not effective and may increase the client's anxiety. Teaching relaxation techniques can be done when the client calms down

66. A client in the hyperactive phase of a mood disorder, bipolar type, is receiving lithium. A nurse identifies that the client's lithium blood level is 1.8 mEq/L. What is the most appropriate nursing action? 1. Continue the usual dose of lithium and note any adverse reactions. 2. Discontinue the drug until the lithium serum level drops to 0.5 mEq/L. 3. Ask the health care provider to increase the dose of lithium because the blood lithium level is too low. 4. Hold the drug and notify the health care provider immediately because the blood lithium level may be toxic.

4 The lithium level should be maintained between 0.5 and 1.5 mEq/L

55. Which is the most important assessment data for a nurse to gather from the client in crisis? 1. The client's work habits 2. Any significant physical health data 3. A history of emotional problems in the family 4. The client's perception of the circumstances surrounding the crisis

4 This assessment assists the nurse to determine what the situation means to the client.

34. A physician is admitted to the psychiatric unit of a community hospital. The client, who was restless, loud, aggressive, and resistive during the admission procedure, states, "I will take my own blood pressure." What is the nurse's most therapeutic response? 1. "Right now you are just another client." 2. "If you would rather, I'm sure you will do it correctly." 3. "I will get the attendants to assist me if you do not cooperate." 4. "I am sorry, but I cannot allow that because I must take your blood pressure."

4 This simply states facts without getting involved in role conflict

76. A nurse is evaluating the medication regimens of a group of clients to determine whether the therapeutic level has been achieved. For which medication should the nurse review the client's serum blood level? 1. Sertraline (Zoloft) 2. Lorazepam (Ativan) 3. Olanzapine (Zyprexa) 4. Valproic acid (Depakene)

4 Valproic acid (Depakene) must reach a therapeutic level to be effective, and the serum level must be monitored for therapeutic and toxic levels of the drug

36. A parent of a 13-year-old adolescent who was recently diagnosed with Hodgkin disease tells a nurse, "I don't want my child to know the diagnosis." How should the nurse respond? 1. "It is best if your child knows the diagnosis." 2. "Did you know the cure rate for Hodgkin disease is high?" 3. "Would you like someone with Hodgkin disease to talk with you?" 4. "Let's talk about your feeling regarding your child's diagnosis."

4 This statement does not prejudge the parent; it encourages communication.

90. Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? Select all that apply. 1. Rigidity 2. Tremors 3. Mydriasis 4. Photophobia 5. Bradykinesia

Answer: 1, 2, 5.

95. A client is admitted to the acute medical unit for severe amphetamine intoxication. Which medications should a nurse anticipate will be prescribed to counteract the effects of stimulant intoxication? Select all that apply. 1. Diazepam 2. Propranolol 3. Benztropine 4. BuPROPion 5. Amitriptyline

Answer: 1, 2.

94. Olanzapine (Zyprexa) is prescribed for a client who experienced agranulocytosis from Clozapine (Clozaril). Which statements indicate that the nurse's teaching about olanzapine has been effective? Select all that apply. 1. "I need to be careful that I do not gain too much weight." 2. "I should be careful so I don't nick myself when I shave." 3. "This medication should help me enjoy pleasurable activities." 4. "I will have to remember to take my benztropine (Cogentin)." 5. "Restlessness can occur when I am taking this medication."

Answer: 1, 3.

53. An adult who has been in a gay relationship for 3 years arrives at the emergency department in a near panic state. The client states, "My partner just left me. I am a wreck." What should the nurse do to help the client cope with this loss? Select all that apply. 1. Identify the client's support systems. 2. Explore the client's psychotic thoughts. 3. Reinforce the client's current self-image. 4. Encourage the client to talk about the situation. 5. Suggest that the client explore personal sexual attitudes.

Answer: 1, 4.

54. Which approaches should a nurse use during crisis intervention? Select all that apply. 1. Active 2. Passive 3. Reflective 4. Interpretative 5. Goal-directed

Answer: 1, 5.

83. A client has been receiving fluphenazine for several months. For which side effects should the nurse assess the client? Select all that apply. 1. Tremors 2. Excess salivation 3. Rambling speech 4. Reluctance to converse 5. Minimal use of nonverbal expression 6. Uncoordinated movement of extremities

Answer: 1, 6.

57. When assisting clients to cope with a crisis, the health care provider should follow the principles of intervention. Place the following interventions in order of their priority. 1. ______ Stabilize the client. 2. ______ Intervene immediately. 3. ______ Encourage self-reliance. 4. ______ Use the available resources. 5. ______ Facilitate understanding of the event.

Answer: 2, 1, 5, 4, 3.

93. Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? Select all that apply. 1. Jaundice 2. Diaphoresis 3. Hyperrigidity 4. Hyperthermia 5. Photosensitivity

Answer: 2, 3, 4.

30. Among members of the nursing team, which functions are registered nurses legally permitted to perform in a mental health hospital? Select all that apply. 1. Psychotherapy 2. Health promotion 3. Case management 4. Prescribing medication 5. Treating human responses

Answer: 2, 3, 5.

41. A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? Select all that apply. 1. "I cry all the time, I am so sad." 2. "Since I retired I have been so depressed." 3. "I would like to end it all with sleeping pills." 4. "Voices say it is okay for me to kill all prostitutes." 5. "My boss makes me so angry by always picking on me."

Answer: 3, 4.

71. A client with schizophrenia who has type II (negative) symptoms is prescribed risperidone (Risperdal). Which outcomes indicate that the medication has minimized these symptoms? Select all that apply. 1. There is less agitation. 2. There are fewer delusions. 3. There is more interest shown in unit activities. 4. The client reports that the hallucinations have stopped. 5. The client performs activities of daily living independently.

Answer: 3, 5.