222 Mental Health Nursing Review Questions

First generation antipsychotic medication (Clozaril) may cause a drop in which lab value?

White Blood Cell count (WBCs). - Normal range: 4,500 to 11,000.

When do you document on a suicidal client?

As often as possible, with the most accurate information and details pertaining to the client.

What priority nursing intervention can help a client with depression?

Assess for suicide risk.

10-year-old client prescribed dextroamphetamine has a nursing diagnosis of imbalanced nutrition: less than body requirements R/T a side effect of anorexia. Which of the following nursing interventions addresses this client's problem? (Select all that apply.) A. Monitor output and sleep patterns daily. B. Administer medications with food to prevent nausea. C. Schedule medication administration after meals. D. Increase fiber and fluid intake to prevent constipation. E. Encourage frequent high-calorie snacks.

C. Schedule medication administration after meals. E. Encourage frequent high-calorie snacks.

The nurse is interviewing a client admitted to an inpatient psychiatric unit with a diagnosis of depressive disorder. Which is the primary goal in the assessment phase of the nursing process for this client? A. To build trust and rapport. B. To identify goals and outcomes. C. To collect and organize information. D. To identify and validate the medical diagnosis.

C. To collect and organize information. - The primary goal in the assessment phase of the interview is to collect and organize data, which would be used to identify and prioritize the client's problems.

Which short-term correctly written outcome would take priority for a client who is diagnosed with moderate IDD and who resorts to self-mutilation during times of peer and staff conflict? A. The client will form peer relationships by end of the shift. B. The client will demonstrate adaptive coping skills in response to conflicts. C. The client will take direction without becoming defensive by discharge. D. The client will experience no physical harm during this shift.

D. The client will experience no physical harm during this shift. - A child diagnosed with moderate IDD who resorts to self-mutilation during times of peer and staff conflict must be protected from self-harm. A realistic, measurable outcome would be that the client would experience no physical harm during this shift.

What is the term for copying another's speech?

Echolalia.

What is the term for copying another's behavior or movements?

Echopraxia.

Common side effects of SSRIs:

- Fatigue. - Stomach upset. - Decreased libido. - Weight fluctuation.

What are risk factors for suicide?

- History of a suicide attempt. - A friend, loves one, or acquaintance who recently committed suicide. - Diagnoses of a mental health disorder. (MDD, bipolar disorder, psychotic disorder, or substance use disorder) - Veterans - Living alone. - Elderly population. - Male gender.

Symptoms of depression:

- Low mood. - Anhedonia. - Difficulty concentrating. - Low self-esteem. - Weight gain or loss.

Which lab value should be monitored in a client receiving Depakote (Valproate)?

- Serum levels. - Liver function tests (LFTs). - CBC every 6 months.

Number the symptoms of an NCD due to Alzheimer's disease as they progress through stages of the disease process. 1. Client is bedfast and aphasic. 2. Client has no apparent memory decline. 3. Client begins to lose things and forget names. 4. Client is unable to recall the day, season, or year. 5. Client needs some assistance with hygiene. 6. Client forgets major events in personal history. 7. Client gets lost when driving a car.

7. Client gets lost when driving a car. 1. Client is bedfast and aphasic. 2. Client has no apparent memory decline. 6. Client forgets major events in personal history. 5. Client needs some assistance with hygiene. 4. Client is unable to recall the day, season, or year. 3. Client begins to lose things and forget names.

A client diagnosed with ODD has an outcome of learning new coping skills through behavior modification. Which client statement or question indicates that behavior modification has occurred? A. "I didn't hit Johnny. Can I have my Tootsie Roll?" B. "I want to wear a helmet like Jane wears." C. "Can I watch television after supper?" D. "I want a puppy right now."

A. "I didn't hit Johnny. Can I have my Tootsie Roll?" - Behavior modification is defined as a treatment modality aimed at changing undesirable behaviors by using a system of reinforcement to bring about the modifications desired. The question implies that the client defensively copes with frustration by lashing out and hitting people. New coping skills have been achieved through behavior modification when the client says, "I didn't hit Johnny. Can I have my Tootsie Roll?" The intervention used to achieve this outcome is a reward system that recognizes and appreciates appropriate behavior, modifying behavior that was previously unacceptable.

A family member of a client, who is being treated for symptoms of a modest decline in cognitive function, asks the nurse, "Is my father's problem reversible?" Which is the most appropriate nursing response? A. "Treatment sometimes can reverse a mild NCD." B. "Unfortunately, major NCD is not reversible." C. "Unfortunately, mild NCD is not reversible." D. "Treatment sometimes can reverse major NCD."

A. "Treatment sometimes can reverse a mild NCD." - A modest decline in cognitive function indicates the presence of mild NCD. Early intervention can prevent or slow progression of mild NCD. A positive prognosis will be dependent on the underlying cause and the severity of the symptoms.

A client on a psychiatric unit tells the nurse, "I'm all alone in the world now, and I have no reason to live." Which response by the nurse would encourage further communication by the client? A. "You sound like you're feeling lonely and frightened." B. "Why do you think that suicide is the answer to your loneliness?" C. "I live by myself and know it can be very lonely and frightening." D. "Just hang in there and, you'll see things will work out."

A. "You sound like you're feeling lonely and frightened." - By understanding the client's point of view, the nurse communicates empathy with regard to the client's feelings.

A nurse suspects a client is experiencing delirium. Which specific assessment information would support this suspicion? A. A decreased level of consciousness with intermittent hypervigilance. B. Slow onset of confusion and agitation. C. Onset is insidious and relentless. D. The symptoms last for 1 month or longer.

A. A decreased level of consciousness with intermittent hypervigilance. - Delirium is characterized by a disturbance of consciousness and a state of awareness that may range from hypervigilance to stupor or semi coma.

The nurse on an inpatient pediatric psychiatric unit is admitting a client diagnosed with autism spectrum disorder. Which would the nurse expect to assess from a genetic perspective? A. A strong connection with siblings. B. An active imagination. C. Abnormalities in physical appearance. D. Absence of language.

A. A strong connection with siblings. - Research has revealed strong evidence that genetic factors may play a significant role in the etiology of autism spectrum disorder. Studies show that parents who have one child with this disorder are at an increased risk for having more than one child with the disorder. Also, monozygotic and dizygotic twin studies have provided evidence of genetic involvement.

A nurse is working with clients with a late-stage NCD due to Alzheimer's disease, which is a priority nursing intervention? A. Assist the client in consuming fluids and food to prevent electrolyte imbalance. B. Reorient the client to place and time frequently to reduce confusion and fear. C. Encourage the client to participate in ADLs promoting self-worth. D. Assist with ambulation to avoid injury from falls.

A. Assist the client in consuming fluids and food to prevent electrolyte imbalance. - Nutritional deficits are common among clients diagnosed with a late-stage NCD due to Alzheimer's disease. These clients must be assisted in consuming fluids and food to prevent electrolyte imbalance. Meeting this physical need would be prioritized over meeting psychological needs.

An 80-year-old client admitted to the emergency department is experiencing fever, dysuria, and urinary frequency. The client is combative and seeing things others do not see. Which nursing diagnosis reflects this client's problem? A. Disturbed sensory perceptions R/T infection AEB visual hallucinations. B. Risk for violence: self-directed R/T disorientation. C. Self-care deficit R/T decreased perceived need AEB disheveled appearance. D. Social isolation R/T decreased self-esteem.

A. Disturbed sensory perceptions R/T infection AEB visual hallucinations. - The nursing diagnosis of disturbed sensory perception is defined as a change in the amount of patterning of incoming internal or external stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. This client is experiencing symptoms of a urinary tract infection (UTI). The client's combativeness and visual hallucinations, caused by septicemia secondary to the UTI, are indicative of a disturbed sensory perception. In an elderly client, a UTI, if untreated, often leads to symptoms of delirium.

A client presents in the emergency department with an acute decline in cognitive ability. The nurse's assessment should include which of the following? (Select all that apply.) A. Family history and a mini-mental state examination (MMSE). B. Laboratory tests and vital signs. C. Toxicology screen for illegal substances. D. Open-ended questions to obtain information. E. Familiarizing the client with the milieu.

A. Family history and a mini-mental state examination (MMSE). B. Laboratory tests and vital signs. C. Toxicology screen for illegal substances.

Which is a diagnostic criterion for the diagnosis of ADHD? A. Inattention. B. Recurrent and persistent thoughts. C. Physical aggression. D. Anxiety and panic attacks.

A. Inattention. - Essential diagnostic criteria for ADHD includes inattention, along with hyperactivity and impulsivity. Children with this disorder are highly distractible and have extremely limited attention spans.

Studies have indicated that drastically reduced levels of acetylcholine are noted in the brains of individuals diagnosed with an NCD due to Alzheimer's disease. Which cognitive deficit is primarily associated with this reduction? A. Loss of memory. B. Loss of purposeful movement. C. Loss of sensory ability to recognize objects. D. Loss of language ability.

A. Loss of memory. - The enzyme acetyltransferase is needed to synthesize the neurotransmitter acetylcholine. Some theorists propose that the primary memory loss that occurs in an NCD due to Alzheimer's disease is the direct result of reduction in acetylcholine available to the brain.

A client diagnosed with binge-eating disorder has a nursing diagnosis of low self-esteem. Which nursing intervention would address this client's problem? A. Offer independent decision-making opportunities. B. Review previously successful coping strategies. C. Provide a quiet environment with decreased stimulation. D. Allow the client to remain in a dependent role throughout treatment.

A. Offer independent decision-making opportunities. - Offering independent decision-making opportunities promotes feelings of control. Making decisions and dealing with the consequences of these decisions should increase independence and improve the client's self-esteem.

Which of the following signs and symptoms supports a diagnosis of depression in an adolescent? (Select all that apply.) A. Poor self-esteem. B. Insomnia and anorexia. C. Sexually acting out and inappropriate anger. D. Increased serotonin levels. E. Exaggerated psychosomatic complaints.

A. Poor self-esteem. B. Insomnia and anorexia. C. Sexually acting out and inappropriate anger. E. Exaggerated psychosomatic complaints.

You are a nurse writing a plan of care for a client diagnosed with an NCD, the nurse considers which of the following secondary prevention interventions? (Select all that apply.) A. Reinforce speech with nonverbal techniques by pointing to and touching items. B. Keep surroundings simple by reducing clutter. C. Offer family ethics consultation or hospice assistance if appropriate. D. Place a large, visible clock and calendar in client's room. E. Talk to family members about genetic predisposition regarding NCD.

A. Reinforce speech with nonverbal techniques by pointing to and touching items. D. Place a large, visible clock and calendar in client's room.

You are a nurse writing writing a plan of care for a client diagnosed with an NCD, the nurse considers which of the following secondary prevention interventions? (Select all that apply.) A. Reinforce speech with nonverbal techniques by pointing to and touching items. B. Keep surroundings simple by reducing clutter. C. Offer family ethics consultation or hospice assistance if appropriate. D. Place a large, visible clock and calendar in client's room. E. Talk to family members about genetic predisposition regarding NCD.

A. Reinforce speech with nonverbal techniques by pointing to and touching items. D. Place a large, visible clock and calendar in client's room.

A nursing diagnosis of self-care deficit R/T memory loss AEB inability to fulfill ADLs is assigned to a client diagnosed with an NCD due to Alzheimer's disease. Which is an appropriate, correctly written, short-term outcome? A. The client participates in ADLs with assistance by discharge. B. The client accomplishes ADLs without assistance after discharge. C. By time of discharge, the client will exhibit feelings of self-worth. D. The client will not experience physical injury.

A. The client participates in ADLs with assistance by discharge. - The client participating in ADLs is a short-term outcome related to the nursing diagnosis of self-care deficit. This outcome meets all the criteria listed in the rationale. It is specific (ADLs), positive (participate), measurable (by discharge), realistic, and client centered.

A client diagnosed with moderate IDD suddenly refuses to participate in supervised hygiene care. Which short-term outcome would be appropriate for this individual? A. The client will comply with supervised hygiene by day three. B. The client will be able to complete hygiene without supervision by day three. C. The client will be able to maintain anxiety at a manageable level by day two. D. The client will accept assistance with hygiene by day two.

A. The client will comply with supervised hygiene by day three. - With appropriately implemented interventions that direct the client back to previously supervised hygiene performance, the short-term outcome of client adherence and participation by day two can be a reasonable expectation. To achieve this outcome, interventions might include exploring reasons for nonadherence; maintaining consistency of staff members; or providing the client with familiar objects, such as an old versus new toothbrush.

A client diagnosed with an NCD has a nursing diagnosis of risk for injury R/T extreme psychomotor agitation. Which would be an appropriate, correctly written short-term outcome related to this problem? A. The client will remain free from physiological harm during this shift. B. The client will ask the nurse for assistance when becoming agitated. C. The client will verbalize staff appreciation by day three. D. The client will demonstrate performance of activities of daily living (ADLs) on discharge.

A. The client will remain free from physiological harm during this shift. - Remaining free from injury is an appropriate short-term outcome for the nursing diagnosis of risk for injury. This short-term outcome meets all the criteria for a correctly written outcome. It is specific (injury), positive (free from), measurable (during this shift), realistic, and client centered.

A client diagnosed with anorexia nervosa has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which long-term, correctly written outcome addresses client problem improvement? A. The client's BMI will be 20 by the 6-month follow-up appointment. B. The client will be free of signs and symptoms of malnutrition and dehydration. C. The client will use one healthy coping mechanism during a time of stress by discharge. D. The client will understand a previous dependency role by the 3-month follow-up visit.

A. The client's BMI will be 20 by the 6-month follow-up appointment. - A normal BMI range is 20 to 25. Achieving the outcome of a BMI of 20 would indicate improvement for the stated nursing diagnosis of imbalanced nutrition: less than body requirements.

In some cultures, therapeutic touch can be perceived as uncomfortable. What nursing interventions should the nurse implement when caring for a client who may have aversions to touch? A. The nurse should avoid touching during the initial interactions. B. The nurse should teach the client to incorporate touch in the communication process. C. The nurse should avoid talking to the client about feelings related to touch. D. The nurse should wear gloves during all client interactions.

A. The nurse should avoid touching during the initial interaction. - This allows the nurse time to accurately evaluate the client's receptivity to touch.

A client on a psychiatric unit says, "It's a waste of time to be here. I can't talk to you anymore." Which would be an appropriate therapeutic nursing response? A. "I find this hard to believe." B. "Are you feeling that no one understands?" C. "I think you should calm down and look on the positive side." D. "Our staff here is excellent, and you are in good hands."

B. "Are you feeling that no one understands?" - Putting into words what the client has only implied or said indirectly is the therapeutic communication technique of "verbalizing the implied." This gives the client the opportunity to agree or disagree with the implication.

On discharge, a client diagnosed with an NCD is prescribed donepezil hydrochloride (Aricept). Which would the nurse include in a teaching plan for the client's family? A. "Donepezil is a sedative/hypnotic used for short-term treatment of insomnia." B. "Donepezil is an Alzheimer's treatment used for mild to moderate NCD." C. "Donepezil is an antipsychotic used for clients diagnosed with NCD." D. "Donepezil is an antianxiety agent used for clients diagnosed with NCD."

B. "Donepezil is an Alzheimer's treatment used for mild to moderate NCD." - Donepezil hydrochloride is a treatment for NCD due to Alzheimer's disease. A decrease in cholinergic function may be the cause of this disease, and donepezil is a cholinesterase inhibitor. This drug exerts its effect by enhancing cholinergic function by increasing the level of acetylcholine.

Which of the following are examples of the therapeutic communication technique of "clarification"? (Select all that apply.) A. "Can we talk more about how you feel about your father?" B. "I'm not sure what you mean when you use the word fragile. C. "I notice that you seem angry today." D. "How does your mood today compare with yesterday?" E. "Can you help me understand what you mean by a 'difficult childhood'?"

B. "I'm not sure what you mean when you use the word fragile. E. "Can you help me understand what you mean by a 'difficult childhood'?" - These examples of "clarification" are an attempt by the nurse to check the nurse's understanding of what has been said by the client and helps the client to make his or her thoughts or feelings more explicit.

A client diagnosed with Tourette's disorder has a nursing diagnosis of social isolation. Which charting entry documents a successful outcome related to this client's problem? A. "Compliant with instructions to use bathroom before bedtime." B. "Made potholder at activity therapy session." C. "Able to distinguish right hand from left hand." D. "Able to focus on TV cartoons for 30 minutes."

B. "Made potholder at activity therapy session." - During activity therapy, clients interact with peers and staff. This participation in a social activity reflects a successful outcome for the nursing diagnosis of social isolation.

A client in an outpatient clinic states, "I am so tired of these medications." Which nursing response would encourage the client to elaborate further? A. "I see you have been taking your medications." B. "Tired of taking your medications?" C. "Let's discuss different ways to deal with your problems." D. "How would your family feel about your stopping your medications?"

B. "Tired of taking your medications?" - This is an example of "restating" and encourages the client to continue to talk about the topic being discussed. Restating lets the client know that the nurse has understood the expressed statement.

A child newly admitted to an inpatient psychiatric unit with a diagnosis of major depressive disorder has a nursing diagnosis of high risk for suicide R/T depressed mood. Which nursing intervention would be most appropriate at this time? A. Encourage the child to participate in group therapy activities daily. B. Engage in one-on-one interactions to assist in building a trusting relationship. C. Monitor the child continuously while no longer than an arm's length away. D. Maintain open lines of communication for expression of feelings.

B. Engage in one-on-one interactions to assist in building a trusting relationship. - A child diagnosed with autism spectrum disorder has impairment in communication affecting verbal and nonverbal skills. Nonverbal communication, such as facial expression, eye contact, or gestures, is often absent or socially inappropriate. Eye-to-eye and face-to-face contact expresses genuine interest in, and respect for, the individual and role-models correct nonverbal expressions.

A child admitted to an inpatient psychiatric unit is diagnosed with separation anxiety disorder. This child is continually refusing to go to bed at the designated time. Which nursing diagnosis best documents this child's problem? A. Nonadherence with rules R/T low self-esteem. B. Ineffective coping R/T hospitalization and absence of major attachment figure. C. Powerlessness R/T confusion and disorientation. D. Risk for injury R/T sleep deprivation.

B. Ineffective coping R/T hospitalization and absence of major attachment figure. - Ineffective coping is defined as the inability to form a valid appraisal of the stressors, ineffective choices of practiced responses, or inability to use available resources. A child diagnosed with separation anxiety often refuses to go to school or bed because of fears of separation from home or from individuals to whom the child is attached. The child in the question is refusing to go to bed as a way to cope with fear and anxiety. The nursing diagnosis of ineffective coping would be an appropriate documentation of this client's problem.

14-year-old client, diagnosed with ADHD, reports that by the end of the school day the prescribed short-acting stimulant is less effective. Which of the following medications would the nurse expect the physician to order? Select all that apply. A. Evekeo (d- & l-amphetamine salt). B. Mydayis (mixed amphetamine based). C. Aptensio (methylphenidate). D. Zenzedi (d-amphetamine sulfate). E. ProCentra (d-amphetamine sulfate).

B. Mydayis (mixed amphetamine based). C. Aptensio (methylphenidate). - Mydayis is a long-acting stimulant medication. Aptensio is a long-acting stimulant medication.

On an inpatient psychiatric unit, a client states "I want to learn better ways to handle my anger." This interaction is most likely to occur in which phase of the nurse-client relationship? A. Pre-interaction phase. B. Orientation (introductory) phase. C. Working phase. D. Termination phase.

B. Orientation (introductory) phase. - This phase involves creating an environment that establishes trust and rapport, and establishing a contract for interventions that details the expectations and responsibilities of the nurse and the client. In this example, the client has built the needed trust and rapport with the nurse. The client now feels comfortable and ready to acknowledge the problem and contract for intervention

A client is diagnosed with intermittent explosive disorder. The clinic nurse should anticipate potentially teaching about which of the following medications? (Select all that apply.) A. Sertraline. B. Paliperidone. C. Buspirone. D. Phenelzine. E. Valproate sodium.

B. Paliperidone. E. Valproate sodium.

Which of the following are examples of primary prevention in a community mental health setting? (Select all that apply) A. Providing ongoing assessment of individuals at high risk for illness exacerbation. B. Teaching physical and psychosocial effects of stress to elementary school students. C. Referring for treatment those individuals in whom illness symptoms have been assessed. D. Monitoring effectiveness of aftercare services. E. Teaching a class on child-rearing skills for a group of new parents.

B. Teaching physical and psychosocial effects of stress to elementary school students. E. Teaching a class on child-rearing skills for a group of new parents. - Both focus on educational programs to help prevent incidence of mental illness.

A child diagnosed with autism spectrum disorder has a nursing diagnosis of impaired social interaction. The child is currently making eye contact and allowing physical touch. Which statement addresses the evaluation of this child's behavior? A. The nurse is unable to evaluate this child's ability to interact socially based on the observed behaviors. B. The child is experiencing improved social interaction as evidenced by making eye contact and allowing physical touch. C. The nurse is unable to evaluate this child's ability to interact socially because the child has not experienced these behaviors for an extended period. D. The child making eye contact and allowing physical touch are indications of improved personal identity, not improved social interaction.

B. The child is experiencing improved social interaction as evidenced by making eye contact and allowing physical touch. - By making eye contact and allowing physical touch, this child is experiencing improved social interaction, making this an accurate evaluative statement.

A client diagnosed with an NCD due to Alzheimer's disease was admitted 72 hours ago. The client states, "Last night I went on a wonderful dinner cruise." This is which type of communication, and what is the underlying reason for its use? A. The client is using confabulation to achieve secondary gains. B. The client is using confabulation to protect the ego. C. The client is using perseveration to divert attention. D. The client is using perseveration to maintain self-esteem.

B. The client is using confabulation to protect the ego. - Clients diagnosed with an NCD due to Alzheimer's disease use confabulation to create imaginary events to fill in memory gaps. This "hiding" is actually a form of denial, which is a protective ego defense mechanism used to maintain self-esteem and avoid losing one's place in the world.

An emaciated client diagnosed with delirium is experiencing sleeplessness, auditory hallucinations, and vertigo. Meclizine has been prescribed. Which client response supports the effectiveness of this medication? A. The client no longer hears voices. B. The client sleeps through the night. C. The client maintains balance during ambulation. D. The client has an improved appetite.

B. The client sleeps through the night. - Meclizine is used to improve vertigo, not sleep problems. A benzodiazepine would be an appropriate short-term intervention to improve sleep.

In what psychiatric disorder may a client experience euphoria?

Bipolar Disorder, manic phase. - Euphoria: a feeling or state of intense excitement and happiness.

Which charting entry would document an appropriate nursing intervention for a client diagnosed with profound IDD? A. "Rewarded client with lollipop after independent completion of self-care." B. "Encouraged client to tie own shoelaces." C. "Kept client in line of sight continuously during shift." D. "Taught the client to sing the alphabet 'ABC' song."

C. "Kept client in line of sight continuously during shift." - A client diagnosed with profound IDD requires constant care and supervision. Keeping this client in line of sight continuously during the shift is an appropriate intervention for a child with an IQ level <20.

A client diagnosed with an NCD states, "I can't believe it's the Fourth of July and it's snowing outside." Which is the nurse's most appropriate response? A. "What makes you think it's the Fourth of July?" B. "How can it be July in winter?" C. "Today is Tuesday, March 12. Look, your lunch is ready." D. "I'll check to see if it's time for your prn haloperidol (Haldol)."

C. "Today is Tuesday, March 12. Look, your lunch is ready." - Orienting the client to person, place, and time, as necessary, refocuses the client to the here and now. Casually reminding the client of a noon meal redirects the client in a manner that is considerate and respectful. It is imperative to preserve the client's self-esteem.

A client who is delirious yells out to the nurse, "You are an idiot, get me your supervisor!" Which is the best nursing response in this situation? A. "You need to calm down and listen to what I'm saying." B. "You're very upset. I'll call my supervisor." C. "You're going through a difficult time. I'll stay with you." D. "Why do you feel that my calling the supervisor will solve anything?"

C. "You're going through a difficult time. I'll stay with you." - Empathetically expressing understanding of the client's situation promotes trust and may have a calming effect on the client. Delirious or confused clients may be at high risk for injury and should be monitored closely.

A client is being admitted to the inpatient psychiatric unit with a diagnosis of bulimia nervosa. The nurse would expect this client to fall within which age range? A. 5 to 10 years old. B. 10 to 14 years old. C. 18 to 22 years old. D. 40 to 45 years old.

C. 18 to 22 years old. - These ages are within the range of late adolescence to early adulthood, in which the onset of bulimia nervosa commonly occurs.

A child diagnosed with severe IDD displays failure to thrive related to neglect and abuse. Which nursing diagnosis would best reflect this situation? A. Altered role performance R/T failure to complete kindergarten. B. Risk for injury: self-directed R/T poor self-esteem. C. Altered growth and development R/T inadequate environmental stimulation. D. Anxiety R/T ineffective coping skills.

C. Altered growth and development R/T inadequate environmental stimulation. -The nursing diagnosis of altered growth and development related to inadequate environmental stimulation would best address this child's problem of failure to thrive. Failure to thrive frequently results from neglect and abuse

A client diagnosed with an NCD has a nursing diagnosis of altered thought process R/T disorientation and confusion. Which nursing intervention should be implemented first? A. Use tranquilizing medications and soft restraints. B. Continuously orient client to reality and surroundings. C. Assess client's level of disorientation and confusion. D. Remove potentially harmful objects from client's room.

C. Assess client's level of disorientation and confusion. - Assessing the client's level of disorientation and confusion should be the first nursing intervention. Assessment of a client diagnosed with an NCD is necessary to formulate a plan of care and to determine specific interventions and requirements for safety.

A client is leaving the inpatient psychiatric facility after 1 month of treatment for anorexia nervosa. Which outcome is appropriate during discharge planning for this client? A. Client will accept refeeding as part of a daily routine. B. Client will perform nasogastric tube feeding independently. C. Client will verbalize recognition of "fat" body misperception. D. Client will discuss importance of monitoring weight daily.

C. Client will verbalize recognition of "fat" body misperception. - The outcome of verbalizing recognition of misperception involving "fat" body image is a long-term outcome, appropriate for discharge planning for a client diagnosed with anorexia nervosa.

After an NCD has been ruled out, a client is diagnosed with pseudodementia (depression). Which of the following client symptoms would support this diagnosis? (Select all that apply.) A. Slow progression of symptoms. B. Impaired attention and concentration. C. Diminished appetite. D. Symptoms diminish as the day progresses. E. Oriented to time and place with no wandering.

C. Diminished appetite. D. Symptoms diminish as the day progresses. E. Oriented to time and place with no wandering.

When admitting a child diagnosed with a conduct disorder, which symptom would the nurse expect to assess? A. Excessive distress about separation from home and family. B. Repeated complaints of physical symptoms such as headaches and stomachaches. C. History of cruelty toward people and animals. D. Confabulation when confronted with wrongdoing.

C. History of cruelty toward people and animals. - A history of physical cruelty toward people and animals is commonly associated with conduct disorder. These children may bury animals alive and set fires intending to cause harm and damage.

A child diagnosed with mild to moderate IDD is admitted to the hospital for an appendectomy. The nurse observes that the child is having difficulty making desires known. Which nursing diagnosis reflects this client's problem? A. Ineffective coping R/T developmental delay. B. Anxiety R/T hospitalization and absence of familiar surroundings. C. Impaired verbal communication R/T developmental alteration. D. Impaired adjustment R/T recent admission to hospital.

C. Impaired verbal communication R/T developmental alteration. - Impaired verbal communication R/T developmental alteration is the appropriate nursing diagnosis for a child diagnosed with mild to moderate IDD who is having difficulties making needs and desires understood to staff members. Clients diagnosed with mild to moderate IDD often have deficits in communication.

Which of the following stimulant medications are prescribed in the treatment of ADHD? Select all that apply. A. Methylphenidate. B. Guanfacine. C. Lisdexamfetamine. D. Amphetamine/dextroamphetamine. E. Clonidine.

C. Lisdexamfetamine. D. Amphetamine/dextroamphetamine. - Methylphenidate is a stimulant medication used in the treatment of ADHD. Lisdexamfetamine is a stimulant medication used in the treatment of ADHD. Amphetamine/dextroamphetamine is a stimulant medication used in the treatment of ADHD.

A child diagnosed with autism spectrum disorder makes no eye contact; is unresponsive to staff members; and continuously twists, spins, and head bangs. Which nursing diagnosis would take priority? A. Personal identity disorder R/T poor ego differentiation. B. Impaired verbal communication R/T withdrawal into self. C. Risk for injury R/T head banging. D. Impaired social interaction R/T delay in accomplishing developmental tasks.

C. Risk for injury R/T head banging. - Children diagnosed with autism spectrum disorder frequently head bang because of neurological alterations, increased anxiety, or catastrophic reactions to changes in the environment. Because the nurse is responsible for ensuring client safety, the nursing diagnosis of risk for injury takes priority.

A foster child diagnosed with ODD is spiteful, vindictive, and argumentative and has a history of aggression toward others. Which nursing diagnosis would take priority? A. Impaired social interaction R/T refusal to adhere to conventional social behavior. B. Defensive coping R/T unsatisfactory child-parent relationship. C. Risk for violence: directed at others R/T poor impulse control. D. Nonadherence R/T a negativistic attitude.

C. Risk for violence: directed at others R/T poor impulse control. - Risk for violence: directed at others is defined as behaviors in which an individual demonstrates that he or she can be physically, emotionally, or sexually harmful to others. Children diagnosed with ODD have a pattern of negativistic, spiteful, and vindictive behaviors. The foster child described in the question also has a history of aggressive behaviors. Because maintaining safety is a critical responsibility of the nurse, risk for violence directed at others would be the priority nursing diagnosis.

A client diagnosed with ADHD and juvenile diabetes is prescribed methylphenidate. Which nursing intervention related to both diagnoses takes priority? A. Teach the client and family that methylphenidate should be taken in the morning because it can affect sleep. B. Teach the client and family to report restlessness, insomnia, and dry mouth. C. Teach the client and family to monitor fasting blood sugar levels daily at various times during treatment. D. Teach the client and family that methylphenidate should be taken exactly as prescribed.

C. Teach the client and family to monitor fasting blood sugar levels daily at various times during treatment. - Methylphenidate lowers the client's activity level, which decreases the use of glucose and increases glucose levels. Because of this, it is necessary to monitor fasting blood sugar levels regularly.

A child diagnosed with a conduct disorder is disruptive and nonadherent with rules in the milieu. Which correctly written outcome, related to this client's problem, should the nurse expect the client to achieve? A. The child will maintain anxiety at a reasonable level by day two. B. The child will interact with others in a socially appropriate manner by day two. C. The child will accept direction without becoming defensive by discharge. D. The child will contract not to harm self during this shift.

C. The child will accept direction without becoming defensive by discharge. - Accepting direction without becoming defensive by discharge is a specific, measurable, positive, realistic, client-centered outcome for this child. The disruption and nonadherence to rules on the milieu is this child's defensive coping mechanism. Helping the child to see the correlation between this defensiveness and the child's low self-esteem, anger, and frustration would assist in meeting this outcome.

Which short-term outcome would be considered a priority for a hospitalized child diagnosed with autism spectrum disorder who bites self when care is attempted? A. The child will initiate social interactions with one caregiver by discharge. B. The child will demonstrate trust in one caregiver by day three. C. The child will not inflict harm on self during the next 24-hour period. D. The child will establish a means of communicating needs by discharge.

C. The child will not inflict harm on self during the next 24-hour period. - A child diagnosed with autism spectrum disorder who bites self when care is attempted is at risk for injury R/T self-mutilation. Self-injurious behaviors, such as head banging and hand and arm biting, are used as a means to relieve tension. Considering that the nurse's primary responsibility is client safety, expecting the child to refrain from inflicting self-harm during a 24-hour period is the short-term outcome that should take priority.

On a 24-hour assessment, the nurse documents that a client diagnosed with a neurocognitive disorder due to Alzheimer's disease presents with aphasia. Which client behavior supports this finding? A. The client is sad and has no ability to experience pleasure. B. The client is extremely emaciated and appears to be wasting away. C. The client is having difficulty forming words. D. The client is no longer able to speak.

C. The client is having difficulty forming words. - Aphasia is the term used when an individual is having difficulty communicating through speech, writing, or signs. This is often caused by dysfunction of brain centers. Aphasia is a cardinal symptom observed in an NCD due to Alzheimer's disease.

The nursing instructor is preparing to teach nursing students about oppositional defiant disorder (ODD). Which fact should be included in the lesson plan? A. Prevalence of ODD is higher in girls than in boys. B. The diagnosis of ODD occurs before the age of 3. C. The diagnosis of ODD occurs no later than early adolescence. D. The diagnosis of ODD is not a developmental antecedent to conduct disorder.

C. The diagnosis of ODD occurs no later than early adolescence. - The symptoms of ODD usually appear no later than early adolescence. A child diagnosed with ODD presents with a pattern of negativity, disobedience, and hostile behavior toward authority figures. This pattern of behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

A client with a long history of alcohol use disorder has been diagnosed with Wernicke-Korsakoff syndrome. With which member of the mental health-care team would the nurse collaborate to meet this client's described need? A. The psychiatrist to obtain an order for neurocognitive disorder medications. B. The psychologist to set up counseling sessions to explore stressors. C. The dietitian to help the client increase consumption of thiamine-rich foods. D. The social worker to plan transportation to Alcoholics Anonymous.

C. The dietitian to help the client increase consumption of thiamine-rich foods. - The dietitian can help the client to increase the intake of thiamine-rich foods. Thiamine deficiency is the cause of Wernicke-Korsakoff syndrome.

A nursing student is studying delirium. Which of the following student statements indicates that learning has occurred? (Select all that apply.) A. "The symptoms of delirium develop over a short time." B. "Delirium permanently affects the ability to learn new information." C. "Symptoms of delirium include the development of aphasia, apraxia, and agnosia." D. "Delirium is a disturbance of consciousness." E. "Delirium is always secondary to another condition."

D. "Delirium is a disturbance of consciousness." E. "Delirium is always secondary to another condition." - Delirium is characterized by symptoms developing rapidly over a short period of time.

A client diagnosed with an NCD due to Alzheimer's disease is displaying signs and symptoms of anxiety, fear, and paranoia. An alteration in which area of the brain is responsible for these signs and symptoms? A. Frontal lobe. B. Parietal lobe. C. Hippocampus. D. Amygdala.

D. Amygdala. - When there is an alteration in the amygdala, the nurse should expect to see impaired emotions—depression, anxiety, fear, personality changes, apathy, and paranoia. The amygdala is a mass of gray matter in the anterior portion of the temporal lobe. It also is believed to play an important role in arousal.

A client newly diagnosed with vascular neurocognitive disorder isolates self because of consistently poor role performance and increased loss of independent functioning. Which correctly written nursing diagnosis reflects this client's problem? A. Disturbed thought processes R/T decreased cerebral circulation AEB disorientation. B. Risk for injury R/T poor role performance AEB decreased functioning. C. Disturbed body image R/T loss of independent functioning AEB tearful, sad affect. D. Low self-esteem R/T loss of independent functioning AEB social isolation.

D. Low self-esteem R/T loss of independent functioning AEB social isolation.

7-year-old client has been prescribed atomoxetine. An appropriate nursing diagnosis is imbalanced nutrition: less than body requirements R/T a side effect of anorexia. Which short-term correctly written outcome is appropriate? A. The client will eat meals in the dining area while socializing. B. The client will maintain expected parameters of growth over the next 6 months. C. The client will verbalize the importance of eating 100% of all meals. D. The client will eat 80% of all three meals throughout the hospital stay.

D. The client will eat 80% of all three meals throughout the hospital stay. - The outcome of the client eating 80% of meals is realistic, has a time frame, and is appropriate for the stated nursing diagnosis.

A client is prescribed quetiapine 50 mg for aggression associated with dementia. The target dose is 200 mg/d. The quetiapine is to be increased by 50 mg/d. On what day of treatment would the client reach the target dose?

Day 4. - The client will reach the target dose on day four. The client will receive 50 mg on day one, then 50 mg each additional day. Every 2 days, the medication will be increased by 100 mg, so it will take 4 days to reach 200 mg.

What causes Wernicke-Korsakoff Syndrome?

History of alcohol use disorder. Often causes secondary dementia as a result of thiamine deficiency.

Example of restating:

If the client says "my life is worthless", the nurse restates with "you feel like your life has no meaning".

What type of delusion carries the highest risk for injury to others?

Paranoid or command hallucinations.

A depressed client states they are too depressed to get up, get dressed, and attend group. The nurse can do what to help them?

Practice hygiene, and help them get dressed and ready for the day.

What disorder may a client present with neologism?

Schizophrenia Neologism: a newly coined word or expression. Making up a word with no meaning could mean disorders or thought and disorganization of thinking and speech.