mental health

A client with 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." The nurse should make which therapeutic response to the client?

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

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse?

Agoraphobia

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?

Removing the client from any immediate danger

The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching?

"I am the nurse and, as such, I'll have you know that all information is kept confidential."

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?

"I cannot discuss any client situation with you."

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?

"What aspects of this situation are the most difficult for you?"

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate?

"What do you and your husband believe is the right thing for your children?"

The nurse is collecting data on a client in crisis. Which question should the nurse ask to determine the client's perception of the precipitating event that led to the crisis?

"What leads you to seek help now?"

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

The nurse is admitting a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis? Select all that apply

Being on a bridge Riding in an elevator Being alone at home Travelling in an airplane

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action

Call for the registered nurse.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the primary health care provider (PHCP)

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis?

Conversion disorder

The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primary means to accomplish work with this client?

Goals and objectives

The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?

Reported hopelessness

The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply.

Hallucinations Delusions Neologism

While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of the National Association of Anorexia Nervosa and Associated Disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.

I'm going to do whatever it takes to get better." "I'll go and participate as much as I can in the group discussions."

The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply.

Lanugo Amenorrhea

The nurse is caring for a client with seasonal affective disorder (SAD). Which type of therapy is considered a first-line treatment for this disorder?

Light therapy

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply.

Looks at old snapshots of family Visits the spouse's grave once a month Visits the senior citizens' center once a month

The nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's blood pressure is elevated at 160/100 mm Hg. Based on this finding, which nursing action would be appropriate?

Notify the registered nurse.

The nurse is assessing a client diagnosed with severe anxiety. Which objective data should the nurse expect to find? Select all that apply.

Oblivious to surroundings Unable to focus on anything Engaging in purposeless activity (walking around aimlessly) Showing unproductive relief behavior (stomping, wringing hands, dropping things)

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the primary health care provider immediately. Which nursing intervention is appropriate?

Offer to assist the client to an examination room until the primary health care provider is notified.

After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. Which response is the nurse's best action?

Privately confront the client with reality.

The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply.

Promoting self-care and independence Helping clients examine self-defeating behaviors and test alternatives Assisting clients with problem solving to help facilitate activities of daily living

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?

Psychomotor retardation and side effects of medication

The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply.

Refer to hallucinations as if they are real. Ask the client directly about the hallucinations. Watch the client for cues that he or she is hallucinating, such as eyes tracking an unheard speaker, muttering, or talking to self. Address any underlying emotion, need, or theme that seems to be indicated by the hallucination, such as fear with menacing voices or guilt with accusing voices.

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action?

Stay with the client at all times.

An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which action would be least helpful in preparing the client to return to a safe and effective care environment?

Suggest that the mother's boyfriend move out of the home.

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action

Tell the client that the primary health care provider will be contacted regarding discharge.

The nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome?

The client reports nightmares involving being stalked when alone at night.

Apraxia Aphasia Agnosia Hyperorality

The nurse is caring for a client with long-term Alzheimer's disease (AD). Which are some of the behavioral manifestations the nurse should expect to observe? Select all that apply.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea

The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply.

Punishment (e.g., punishment applied after the client has had an alcoholic drink) Cognitions (verbal or pictorial events) based on attitudes or assumptions developed from previous experiences. These cognitions may be fairly accurate, or they may be distorted. Pairing of a maladaptive behavior with a noxious stimulus (e.g., pairing the sight and smell of alcohol with electric shock), so that anxiety or fear becomes associated with the once-pleasurable stimulus

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially

Use an indirect light source and turn off the television.

The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse plans to use which communication technique when developing strategies that will promote adequate nutrition and encourage the client to discuss feelings?

Use open-ended questions and silence.

A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply.

Cutoffs Conflict Over involvement

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

Incoordination Mental confusion Muscle hyperirritability

Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply.

Medication management Monitoring and documenting behavioral changes Notifying the health care provider of behavioral changes Planning care for the needs of those clients with mental illness

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. Which is important for the nurse to understand when planning?

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.

A client 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 therapeutic response should the nurse make to the client?

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

The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care?

Provide safety for both the client and other clients on the unit.

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment should include which intervention?

The client shampoos and dries the hair, freeing it of all hair spray and creams.

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion?

The mother should restrict the amount of chocolate and caffeine products in the home.

The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client?

"I can see that you are upset. I'll be back in a few minutes to see how you are doing

A client is scheduled to have electroconvulsive therapy (ECT). Which information should the nurse tell the client?

Amnesia of events occurring near the period of the therapy is common.

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply.

Severe suicidal tendencies Extremely unstable medical and psychiatric conditions Desire for punishment of client or convenience of staff Delirium or dementia leading to inability to tolerate decreased stimulation Severe drug reactions or overdoses or need for close monitoring of drug dosages

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

You must be feeling all alone at this point."