Comprehensive NCLEX Review-mental health

the nurse is leading a "current evens group" with chronic psychiatric clients.. one group member states "clara barton was my nurse during my last hospitalization.. she was a very mean nurse and wasn't nice to me".. which response is best for the nurse to make a) what did she do to you that was so mean b) I didn't know Clara Barton was a nurse c) Clara Barton was not your nurse d) Clara Barton started the American Red Cross

Clara Barton started the American Red Cross

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? a) Suppressing feelings of anxiety b) Identifying anxiety-producing situations c) Continued contact with a crisis counselor d) Eliminating all anxiety from daily situations

Identifying anxiety-producing situations

the nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms SATA a) speaking slowly and simply b) allow the client extra time to complete tasks c) observe and encourage food and fluid intake d) encourage milk exercise and short walks on the unit e) place the client on suicide precautions f) permit rest periods as needed

a, b, c, d, f

which interventions are most appropriate for caring for a client in alcohol withdrawal SATA a) monitor vital signs b) provide a safe environment c) address hallucinations therapeutically d) provide stimulation in the environment e) provide reality orientation as appropriate f) maintain NPO status

a, b, c, e

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client SATA a) restating b) active listening c) asking the client, "Why?" d) maintain neutral responses e) providing acknowledgement and feedback f) giving advice and approval or disapproval

a, b, d, e

the home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care a) ask the client why he started taking illegal drugs b) ask the client about the amount of drug use and its effect c) ask the client how long he thought that he could take drugs without someone finding out d) do not ask any questions for fear that the client is in denial and will throw the nurse out of the home

ask the client about the amount of drug use and its effect

a male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take a) ignore the behavior and make no response at all to his delusional statements b) assess the content of the hallucinations by asking the client what he is hearing c) reassure the client by telling him that his fear of the admission procedure is to be expected d) tell the client that no one is accusing him of murder and remind him that the hospital is a safe place

assess the content of the hallucinations by asking the client what he is hearing

a client is admitted to the mental health unit after an attempted suicide by hanging. the nurse can best ensure client safety by which action a) requesting that a peer remain with the client at all times b) removing the client's clothing and placing the client in a hospital gown c) assigning to the client a staff member who will remain with the client at all times d) admitting the client to a seclusion room where all potentially dangerous articles are removed

assigning to the client a staff member who will remain with the client at all times

a client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. because of this hypersensitivity to a reaction from her, the client remains homebound. the home care nurse develops a plan of care that addresses which personality disorder a) avoidant b) borderline c) schizotypal d) obsessive-compulsive

avoidant

the nurse has been closely monitoring a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. which nursing intervention is most helpful to this client at this time SATA a) initiate confinement measures b) acknowledge the client's behavior c) assist the client to an area that is quiet d) maintain a safe distance from the client e) allow the client to take control of the situation

b, c, d

The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. a) Libel b) Battery c) Assault d) Slander e) False Imprisonment

b, c, e

a hospitalized client is started on a MAOI for the treatment of depression. the nurse should instruct the client that which foods are acceptable to consume while taking this medication SATA a) figs b) yogurt c) crackers d) aged cheese e) tossed salad f) oatmeal raisin cookies

c, e

a hospitalized client with a hx of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want anymore treatment. I have things that I have to do right away". The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. after the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take a) call the nursing supervisor b) call security to block all exit areas c) restrain the client until primary HCP can be reached d) tell the client that the client cannot return to this hospital again if the client leaves now

call the nursing supervisor

a client give the home health nurse a bottle of clomipramine. the nurse notes that the medication has not been taken by the client in two months. which behavior observed in the client wold validate noncompliance with this medication a) complaints of insomnia b) complaints of hunger and fatigue c) a pulse rate less than 60bpm d) frequent hand washing with hot, soapy water

frequent hand washing with hot, soapy water

the nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. before d/c, what instruction should the nurse provide to the client a) get adequate sunlight b) continue driving as usual c) avoid foods rich in potassium d) get up slowly when changing positions

get up slowly when changing positions

a 22 year old male client is admitted to the emergency center following a suicide attempt. his records reveal that this is his third suicide attempt in the past two years. he is conscious but does not respond to verbal commands for treatment. which assessment finding should prompt the nurse to prepare the client for gastric lavage a) the family reports that he took an entire bottle of acetaminophen (Tylenol) b) he is unresponsive to instructions and is unable to cooperate with emetic therapy c) those with repeated suicide attempts desire punishment to relieve their guilt d) he ingested the drug 3 hours prior to admission to the emergency center

he is unresponsive to instructions and is unable to cooperate with emetic therapy

a client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make a) let's talk about what is right with your life b) things probably aren't as bad as they seem right now c) how can I help d) I hear how miserable you are, but things will get better soon

how can I help

the nurse is assessing a client who as admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium a) hypotension, ataxia, hunger b) stupor, lethargy, muscular rigidity c) hypotension, coarse hand tremors, lethargy d) hypertension, changes in LOC, hallucination

hypertension, changes in LOC, hallucination

a client on the psychiatric unit appears to imitate a certain nurse on the unit.. the client seeks out this particular nurse and imitates her mannerisms. the nurse knows that the client is using which defense mechanism a) sublimation b) identification c) repression d) introjection

identification

The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents? a) if he has a desire to quit taking drugs b) if he has seemed depressed recently c) if a drug overdose has ever occurred before d) if he might have taken any other drugs

if he might have taken any other drugs

the nurse is teaching a client who is being started on imipramine about the medication. the nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication a) in 2 months b) in 2-3 weeks c) during the first week d) during the 6th week of administration

in 2-3 weeks

the nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. which information should the nurse incorporate in the discussion a) consume a low-fiber diet b) increase fluids and bilk in the diet c) rest if the heart begins to beat rapidly d) walk if you have difficulty urinating because this is a normal side effect

increase fluids and bilk in the diet

a moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured". Based on the client's behavior and statement, which intervention should the nurse include in the plan a) suggesting a reduction of medication b) allowing increased "in-room" activities c) increasing the level of suicide precautions d) allowing the client off-unit privileges as need

increasing the level of suicide precautions

the ED nurse is caring for an adult client who is a victim of family violence. which priority intervention should be included in the discharge instructions a) information regarding shelters b) instructions regarding calling the police c) instructions regarding self-defense classes d) explaining the importance of leaving the violent situation

information regarding shelters

the nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client focused action should the nurse engage in during the working phase of the nurse-client relationship a) exploring the client's ability to function b) exploring the client's potential for self-harm c) inquiring about the client's perception or appraisal of why the rescue was unsuccessful d) inquiring about and examining the client's feelings for any that may block adaptive coping

inquiring about and examining the client's feelings for any that may block adaptive coping

the nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. the nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate a) interrupt the client and weight her immediately b) interrupt the client and offer to take her for a walk c) allow the client to complete her exercise program d) tell the client that she is not allowed to exercise rigorously

interrupt the client and offer to take her for a walk

the nurse visits a client at home. the client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication a) "I see" b) "Really?" c) "you're having difficulty sleeping?" d) "sometimes I have trouble sleeping too"

"you're having difficulty sleeping?"

a client with schizophrenia has been started on medication therapy with clozapine. the nurse should assess the results of which lab study to monitor for adverse effects from this medication a) platelet count b) blood glucose level c) LFTs d) WBC

WBC

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? a) Admitting to having a problem b) Substituting other activities for gambling c) Stating that the gambling will be stopped d) Discontinuing relationships with people who gamble

Admitting to having a problem

the nurse is performing a follow-up teaching session with a client discharge 1 month ago. The client is taking fluoxetine. which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the medication a) CV symptoms b) GI dysfunction c) problems with mouth dryness d) problems with excessive sweating

GI dysfunctions

a hospitalized client has begun taking bupropion as an antidepressant agent. the nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication a) constipation b) seizure activity c) increased weight d) dizziness when getting upright

seizure activity

a client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2 bedroom. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa a) a client with pneumonia b) a client undergoing diagnostic tests c) a client who thrives on managing others d) a client who benefit from the client's assistance at mealtime

a client undergoing diagnostic tests

a client's medication sheet contains a prescription for sertraline. to ensure safe administration of the medication, how should the nurse administer the dose a) on an empty stomach b) at the same time each evening c) evenly spaced around the clock d) as needed when the client complains of depression

at the same time each evening

the nurse is conducting a group therapy session. during the session, a client diagnosed with mania consistently disrupts the groups interactions. which intervention should the nurse initially implement a) setting limits on the client's behavior b) asking the client to leave the group session c) asking another nurse to escort the client out of the group session d) telling the client that they will not be able to attend any future group sessions

setting limits on the client's behavior

a client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus and tremors. The lithium level is 2.5 mEq/L. the nurse plans care based on which representation of this level a) toxic b) normal c) slightly above normal d) excessively below normal

toxic

a client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern a) "I don't believe this is true" b) "The guards are not out to kill you" c) "Do you feel afraid that people are trying to hurt you?" d) "What makes you think the guards were sent to hurt you?"

"Do you feel afraid that people are trying to hurt you?"

the nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. the neighbor says to the nurse, "How is Carl doing? She is my best friend and is seen at your clinic every week". Which is the most appropriate nursing response a) "I cannot discuss any client situation with you" b) "If you want to know about Carol, you need to ask her yourself" c) "only because you're worried about a friend, I'll tell you that she is improving" d) "Being her friend, you know she is having a difficult time and deserves her privacy"

"I cannot discuss any client situation with you"

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be: a) "Why don't you tell your spouse about this" b) "What do you find difficult about this situation" c) "This is not the best time to make that decision" d) "I agree with you. You should get out of this situation"

"What do you find difficult about this situation"

a client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic a) "Have you shared your feelings with your family?" b) "I think we should talk more about your anger with your family" c) "You're feeling angry that your family continues to hope for you to be cured?" d) "You are probably very depressed which is understandable with such a diagnosis"

"You're feeling angry that your family continues to hope for you to be cured?"

a depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response a) "Have you talked to your family about this" b) "everyone feels this way when they are depressed" c) "you will feel better once your medication begins to work" d) "you sound very upset. are you thinking of hurting yourself"

"you sound very upset. are you thinking of hurting yourself"

the nurse is planning care for a client being admitted to the nursing unit who attempted suicide. which priority nursing intervention should the nurse include in the plan of care a) 1:1 suicide precautions b) suicide precautions with 30 min checks c) checking the whereabouts of the client every 15 min d) asking the client to report suicidal thought immediately

1:1 suicide precautions

The police arrive at the ED with a client who has seriously lacerated both wrists. The initial nursing action is to: a) Administer an antianxiety agent b) Examine and treat the client's wounds c) Place the client in a room with 1:1 observation d) Explain to the client that once his wounds are repaired he must go with the police to jail

Examine and treat the client's wounds

which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal a) the adolescent gives away a DVD and a cherished autographed picture of the performer b) the adolescent runs out of the therapy group, swearing at the group leader and to her room c) the adolescent become angry while speaking on the telephone and slams down the receiver d) the adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking

the adolescent gives away a DVD and a cherished autographed picture of the performer

the nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event a) witnessing a murder b) the death of a loved one c) the fire that destroyed the client's home d) a recent rape episode experienced by the client

the death of a loved one

a nurse working in the ED of a children's hospital admits a child whose injuries could have resulted from abuse. which statement most accurately describes the nurse's responsibility in cases of suspected child abuse a) the nurse should note in the client's record any suspicions of child abuse so that a hx of such suspicions can be tracked b) the nurse should confirm any suspicions of child abuse with the HCP before reporting to the authorities c) the nurse should obtain objective data such as xrays before reporting suspicions to the authorities d) the nurse should report any case of suspected child abuse of the nurse in charge

the nurse should report any case of suspected child abuse of the nurse in charge

a client diagnosed with delirium becomes disoriented and confused at night. which intervention should the nurse implement initially a) move the client next to the nurse's station b) use an indirect light source and turn off the TV c) keep the TV and a soft light on during the night d) play soft music during the night and maintain a well-lit room

use an indirect light source and turn off the TV

a client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat a) using open-ended questions and silence b) sharing personal preference regarding food choices c) documenting reasons why the client does not want to eat d) offering opinions about the necessity of adequate nutrition

using open-ended questions and silence

the nurse is conducting an initial assessment of a client in crisis. When assessing the clients perception of the precipitating event that led to the crisis, which is the most appropriate question a) with whom do you live b) who is available to help you c) what leads you to seek help now d) what do you usually do to feel better

what leads you to seek help now

the nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. which activity would be most appropriate for this client a) chess b) writing c) board games d) group exercise

writing

the nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement a) "I no longer feel that I deserve the beatings my husband inflicts on me" b) "My attendance at the meetings has helped me see that I provoke my husband's violence" c) "I enjoy attending the meetings because they get me out of the house and away from my husband" d) "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics"

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

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. What is the most appropriate nursing response? a) "You need to try to be realistic. The rape did not just occur." b) "It will take some time to get over these feelings about your rape." c) "Tell me more about the incident that causes you to feel like the rape just occurred." d) "What do you think that you can do to alleviate some of your fears about being raped again?"

"Tell me more about the incident that causes you to feel like the rape just occurred."

the nurse is preparing a client with schizophrenia a hx of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information a) "My medications will help my anxious feelings" b) "I'll go to support groups and talk about what I am feeling" c) "When I have command hallucinations, I'll call a friend for help" d) "I need to get enough sleep and eat well to help prevent feeling anxious"

"When I have command hallucinations, I'll call a friend for help"

the nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. which statement would be most appropriate to make to this client a) "You need to stop that behavior now" b) "you will need to be placed in seclusion" c) "You seem restless; tell me what is happening" d) "You will need to be restrained if you do not change your behavior"

"You seem restless; tell me what is happening"

a client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. the nurse is implementing which therapeutic approach a) milieu therapy b) interpersonal therapy c) behavior modification d) support group therapy

milieu therapy

a client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention a) encouraging quiet reading and writing for the first few days b) identification of physical activities that will provide exercise c) no socializing activities until the client asks to participate in milieu d) a structured program of activities in which the client can participate

a structured program of activities in which the client can participate

the nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. which assessment findings should the nurse expect to note SATA a) dental decay b) moist, oily skin c) loss of tooth enamel d) electrolyte imbalance e) body weight well below ideal range

a, c, d

a female client with OCD is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan SATA a) antidepressant meds increase serotonin levels b) obsessions cause compulsions c) anxiety is the key reason for OCD d) compulsions relieve anxiety e) obsessive thoughts are linked to levels of neurochemicals

a, c, d, e

the nurse is planning the care for a 32 year old male client with acute depression. which nursing intervention would be best in helping this client deal with his depression a) encourage the client to explore the rationale for his depression b) assist the client in exploring feelings of shame, anger and guilt c) allow the client to initiate and determine activities of daily living d) ensure that the client's day is filled with group activities

assist the client in exploring feelings of shame, anger and guilt

a client is scheduled for discharge and will be taking phenobarbital for an extended period. the nurse would place highest priority on teaching the client which point that directly relates to client safety a) take the medication only with meals b) take the medication at the same time each day c) use a dose container to help prevent missed doses d) avoid drinking alcohol while taking this medication

avoid drinking alcohol while taking this medication

the nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include a) increase socialization of the client with peers b) avoid using a whisper voice in front of the client c) begin to educate the client about social supports in the community d) have the client sign a release of information to appropriate parties for assessment purposes

avoid using a whisper voice in front of the client

a client receiving tricyclic antidepressants arrives that mental health clinic. which observation would indicate that the client is following the medication plan correctly a) client reports not going to work for the past week b) client complains of not being able to "do anything" anymore c) client arrives at the client neat and appropriate in appearance d) client reports sleeping 12 hours per night and 3-4 hours during the day

client arrives at the client neat and appropriate in appearance

a client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. which action should the nurse take initially a) contact the HCP b) call the client's family to arrange for transportation c) attempt to persuade the client to stay, "for only a few more days" d) tell the client that leaving would likely results in an involuntary commitment

contact the HCP

a 35 year old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. the most appropriate action for the nurse is to take is to a) ignore the client's paranoid ideation to extinguish these behaviors b) encourage the client to actively participate in assigned activites on the unit c) explain to the client that his suspicions are false d) place a lock on the client's closet

encourage the client to actively participate in assigned activites on the unit

when reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. based on this type of admission, the nurse should provide which intervention for this client a) monitor closely for harm to self or others b) assist in completing an application for admission c) supply the client with written information about her/his mental health problem provide an opportunity for the family to discuss why they felt the admission was needed

monitor closely for harm to self or others

a client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting and drowsiness. what action should the nurse take a) notify the HCP immediately and prepare for administration of an antidote b) notify the HCP of the symptoms prior to the next administration of the drug c) hold the medication and refuse to administer additional amounts of the drug d) record the symptoms as normal side effects and continue administration of the prescribed drug

notify the HCP of the symptoms prior to the next administration of the drug

a 27 year old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. she is demanding and active. which intervention should the nurse include in this client's plan of care a) encourage her to identify feelings of anger b) provide a structured environment with little stimuli c) schedule her to attend various group activities d) reinforce her ability to make her own decisions

provide a structured environment with little stimuli

the nurse observes that a client is pacing, agitated and presenting aggressive gestures. The client's speech pattern is rapid and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care a) provide safety for the client and other clients on the unit b) provide the client on the unit with a sense of comfort and safety c) assist the staff in caring for the client in a controlled enviornment d) offer the client a less stimulating area in which to calm down and gain control

provide safety for the client and other clients on the unit

On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder? a) personality b) anxiety c) psychotic d) neurotic

psychotic

a woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond a) this does not sound like rape. did you change your mind about having sex after the fact b) rape is not limited to strangers and frequently occurs by someone who is known to the victim c) you must feel betrayed but maybe you might have led him on d) I would be very upset and mad if my best friend did that to me

rape is not limited to strangers and frequently occurs by someone who is known to the victim

a client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. the nurse determines that the medication is effective if the absence of which manifestations has occurred a) paranoid thought process b) rapid heartbeat or anxiety c) alcohol withdrawal symptoms d) thought broadcasting or delusions

rapid heartbeat or anxiety

the nurse in the ED is caring for a young victim of sexual assault. The client's physical assessment is complete and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous and bewildered at times. How should the nurse interpret these behaviors a) signs of depression b) reactions to a devastating event c) evidence that the client is a high suicide risk d) indicative of the need for hospital admission

reactions to a devastating event

the nurse is caring for a client just admitted to the mental health unit and is diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention a) ask direct questions to encourage talking b) leave the client alone so as to minimize external stimuli c) sit beside the client in silence with simple open-ended questions d) take the client into the dayroom with other clients to provide stimulation

sit beside the client in silence with simple open-ended questions

the nurse notes that a client with schizophrenia and receiving an anti-psychotic medication is moving her mouth, protruding her tongue and grimacing as she watches TV. the nurse determines that the client is experiencing which medication complication a) parkinsonism b) tardive dyskinesia c) hypertensive crisis d) neuroleptic malignant syndrom

tardive dyskinesia

what is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session a) ask the client to leave the group for this session only b) refer the client to another group that includes other manic clients c) tell the client to stop monopolizing in a firm but compassionate manner d) thank the client for the input, but inform the client that others now need a chance to contribute

thank the client for the input, but inform the client that others now need a chance to contribute

on review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior a) fearfulness regarding treatment measures b) anger and aggressiveness directed towards others c) an understanding of the pathology and symptoms of the diagnosis d) a willingness to participate in the planning of the care and treatment plan

a willingness to participate in the planning of the care and treatment plan

the nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor a) a crisis state indicates that the client has a mental illness b) a crisis state indicates that the client has an emotional illness c) presenting symptoms in a crisis situation are similar for all clients experiencing a crisis d) a client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client

a client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client

which nursing interventions are most appropriate for a hospitalized client with mania who is exhibiting manipulative behavior SATA a) communicate expected behaviors to the client b) ensure that the client knows that they are not in charge of the nursing unit c) assist the client in identifying ways of setting limits on personal behaviors d) follow through about the consequences of behavior in a nonpunitive manner e) enforce rules by informing the client that he/she will not be allow to attend therapy groups f) have the client state the consequences for behaving in ways that are view as unacceptable

a, c, d, f

the nurse should plan which goals of the termination stage of group development SATA a) the group evaluates the experience b) the real work of the group is accomplished c) group interactions involves superficial conversation d) group members become acquainted with one another e) some structuring of group norms, roles and responsibilities takes place f) the group explores members' feelings about the group and the impending separation

a, f

a client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication a) "you have everything to live for" b) "why do you see yourself as a failure?" c) "feeling like this all part of being depressed" d) "You've been feeling like a failure for a while?"

"You've been feeling like a failure for a while?"

a client is admitted with a recent history of severe anxiety following a home invasion and robbery. during the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD SATA a) "I'm afraid of spiders" b) "I keep reliving the robbery" c) "I see his face everywhere I go" d) "I don't want anything to eat now" e) "I might have died over a few dollars in my pocket" f) "I have to wash my hands over and over again many times"

b, c, e

a client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. when diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. the nurse plans care based on which mental health condition a) psychosis b) repression c) conversion disorder d) dissociative disorder

conversion disorder

a manic client beings to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement a) place the client in seclusion for 30 min b) tell the client that the behavior is inappropriate c) escort the client to their room with the assistance of other staff d) tell the client that their telephone privileges are revoked for 24 hours

escort the client to their room with the assistance of other staff

The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s) a) shuffling gait and hand tremors b) fever of 102 F c) urinary retention d) dizziness when standing

fever of 102 F

when a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. the nurse plans care based on which purpose of this approach a) providing a supportive enviornment b) examining intrapsychic conflicts and past issues c) emphasizing social interaction with clients who withdraw d) helping the client to examine dysfunctional thoughts and beliefs

helping the client to examine dysfunctional thoughts and beliefs