Mental Health

A man calls the suicide prevention hotline and states that he is going to kill himself. Which of the following questions should the nurse ask first?

"How do you plan to kill yourself?"

A 19 year-old client is paralyzed in a car accident. Which of the following statements used by the client would indicate to the nurse that the client was using the mechanism "suppression"?

"I don't remember anything about what happened to me."

The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies, "if you want I can go naked for you." The most therapeutic response by the nurse is...

"I only need access to your arm. Putting up your sleeve is fine."

A client diagnosed with PTSD is close to discharge. Which client statement indicates that teaching about psychosocial causes about PTSD was effective?

"I understand the event I experienced, how I deal with it, and my support systems all affect the process of my disorder."

A client asked the nurse to kill the bugs that are crawling on the floor in her room. The nurse does not see any bugs and suspects the client is hallucinating. Which of the following statements by the nurse would be most appropriate?

"It may seem to you there are bugs crawling on the floor, but I do not see any bugs."

The client states to the nurse, "I see headless people walking down the hall at night." Which nursing response is appropriate?

"It must be frightening. I realize this is real for you, but there are no headless people here."

A student nurse is going over a plan of care for a client experiencing a crisis in a situation. Number the following in priority order.

1. Assess for suicidal and homicidal ideation 2. Establish a working relationship by actively listening 3. Discuss coping skills used in the past and if they were effective 4. Develop a plan of action for dealing with future crises 5. Evaluate the plan's effectiveness

Although symptoms of schizophrenia occur in various times of the lifespan, what area is the highest risk for diagnosis? (when they are younger)

20 year old man

Which client would the charge nurse assign to an agency nurse who is new to the psychiatric setting? (most stable client)

A client admitted four days ago diagnosed with agoraphobia (phobia of pain)

Which client has the best chance of a positive prognosis?

A client diagnosed with schizophrenia compiling with the antipsychotic medications and participating in psychosocial therapy

A nurse is assessing a client at the inpatient psychiatric unit. Which client would require immediate intervention?

A client experiencing rapid, pressurized speech ignoring personal boundaries

A nurse has received an evening report. Which client would the nurse assess FIRST?

A client pacing the hallways stating that their anxiety level is a 8/10

Which client would a charge nurse assign to an agency nurse working in an inpatient psychiatric unit for the first time?

A client rating mood of 3/10, but attending group therapies.

When planning the care of a client who is experiencing post-traumatic stress disorder, the nurse identifies which of the following as an appropriate goal? The client will report...

A decrease in flashbacks and nightmares

A client is on Lithium. The physician then prescribes (a -pam medication). The client has pressured speech and heavy makeup. What is a potential reason for this client's behavior?

A side effect of the pam (Celexa) medication

Nursing care for a client with bipolar disorder: the client paces endlessly in the halls and makes hostile comments to other clients. The client resists the nurse's attempts to remove him to his room. Which of the following options is the most important?

Administer Haloperidol IM.

The nurse cares for a client diagnosed with bipolar disorder. The client paces endlessly in the halls and makes hostile comments to the other clients. The client resists urges for the nurse to remove him to a room in the unit. Which of the following actions by the nurse is most appropriate?

Administer Haloperidol/Haldol IM.

A client with a history of post-traumatic stress disorder is panting and breathing heavily while shouting out some strange words. The nurse reviews the nursing assessment and understands that the client is practicing a form of relaxation called power breathing. The best action for the nurse to take is to...

Allow privacy, but check on the client frequently

An agitated client throws a chair across the day room on the psychiatry floor and threatens other clients with physical harm. Which of the following should the nurse perform FIRST?

Assemble the staff to remove the client from the room (if you go in the room to remove the other patients he will attack on the patients/staff on the way out)

The nurse is talking with a client who just had a beautiful bouquet of roses delivered. Suddenly the client becomes tearful and stares out the window. The client has a history of sexual abuse. Which of the following should the nurse include in the plan of care for this client?

Assess if the client is having a flashback

A client is prescribed sertraline (zoloft). To guarantee a safe administration of the medication, a nurse would administer the dose:

At bedtime

Clozapine is contraindicated for which of the following conditions?

Bone marrow depression

A patient diagnosed with depression taking Amitriptyline is experiencing cardiac dysrhythmias with SOB. Which side effects of this medication is the nurse most concerned about?

Cardiac dysfunction

The nurse is caring for a client that is assuming bizarre positions for long periods of time. To which diagnosis category of schizophrenia would this client most likely be assigned?

Catatonic

A nurse is giving instructions to a client taking risperidone (Risperdal). The nurse advises the client to which of the following?

Change position slowly

A schizophrenic patient on Haldol has restlessness and fidgeting. Which medication would be given at this time?

Cogentin

A client with a long history of schizophrenia, which has been controlled by a haloperidol. During an admission assessment resulting from an exacerbation of the disease, the nurse notices a continuous restlessness of fidgeting. Which medication would the nurse expect the physician to prescribe?

Cojecta/Benztropine phezaline (anti-parkinson drug)

The nurse may encounter clients with concerns on sexuality. The most basic factor in the intervention with clients in the area of sexuality is...

Comfort with one's own sexuality

When instructing a student nurse about suicide, the registered nurse emphasizes that assessment begins by...

Detection of risks (SAD PERSONS mnemonic)

A client notifies the staff member of current suicidal ideation. Which intervention by the nurse would take priority?

Determine if the client has a specific plan

A newly admitted client is diagnosed with PTSD. Which behavioral symptoms would the nurse expect to assess?

Diminished participation in significant activities

A 32-year-old man hospitalized diagnosed with bipolar disorder disrupts the unit activities. Which of the following approaches would be most appropriate for the nurse to implicate at this time?

Distract the client and escort him back to his room

A nurse provides instructions to a client taking fluoxetine (prozac), a selective serotonin reuptake inhibitor antidepressant. The nurse tells the client to take the medication

Early in the morning

Haloperidol (Haldol) 5 mg tid is ordered for a client with Schizophrenia. Two days later, the client complains of "tight jaws and a stiff neck." The nurse should recognize that these complaints are which of the following?

Early symptoms of extrapyramidal reactions to the medication

A nurse is caring for a depressed client who spends most of the day sitting in the window and is about to implement a physical activity plan for him. The nurse knows that the purpose of this plan is which of the following?

Encourage social ideation and improve self esteem

A client newly admitted into the inpatient psychiatric unit has a diagnosis of pedophilia. When working with this client, which should be the nurse's initial reaction?

Evaluate the nurse's feelings regarding the client

A client who has been taking buspirone (BuSpar) for two months returns to the clinic for a follow-up. The nurse determines that the medication is effective if there is an absent display of?

Feelings of panic, fear, and uneasiness

A newly admitted client diagnosed with major depressive disorder isolates himself in the room upstairs and looks out the window. Which nursing intervention is most appropriate to establish a nurse-client relationship?

Frequently sit with the client

Which is the best indicator of success in the long term management of the client in gender and personality disorder?

He learns to verbalize his feelings and concerns

Methylphenidate (Ritalin) is prescribed to an 8-year-old child for the treatment of ADHD. The nurse will most likely monitor which of the following during medication therapy?

Height and weight

A patient is prescribed haloperidol (Haldol) for the management of schizophrenia. Before administering the medication to the patient, the healthcare provider observes facial grimacing and tongue thrusting. Which of the following interventions should the healthcare provider perform first?

Hold the medication and continue to assess the patient

For the past year, a client has been taking Haldol. The nurse notices twitching on the right side of the client's face and tongue movement. Which nursing intervention takes priority?

Hold the medication and report to the MD

A client diagnosed with major depressive disorder is prescribed an MAOI drug phenelzine/Nardil. Which teaching should the nurse go over?

Instruct the client of the food-drug drug-drug interactions

Which of the following statements is true for gender identity disorder?

It is the desire to live or involve in reactions of the opposite sex

A patient diagnosed with bipolar disorder is prescribed Lithium. What important information should the nurse include in the teaching about the drug?

It is well absorbed with the GI

A nurse is caring for a patient in the pediatric clinic. The mother of a 14 year old male saying he masturbates. Which of the following by the nurse is the most appropriate?

Masturbation is natural (as long as he is not doing it in public)

A client is experiencing suicidal ideation with a plan to overdose on his medication is admitting to an inpatient psychiatric unit. Diazepam is prescribed. Which nursing intervention takes priority?

Monitor closely, the client may be cheeking the medication

Which intervention takes priority of a newly admitted client experiencing suicidal ideation?

Monitor the client at close, but irregular intervals

What is required for the effective treatment of schizophrenia?

Multidisciplinary combination of pharmacology and psychosocial care

The risk of experiencing serotonin syndrome when SSRIs are given with monoamine oxidase inhibitors such as phenelzine (Nardil). Serotonin syndrome is best characterized in which of the following?

Muscle rigidity

The risk of experiencing serotonin syndrome when SSRIs are given with monoamine oxidase inhibitors such as phenelzine. Serotonin syndrome is best characterized in which of the following?

Muscle rigidity and high fever

A patient with a history of schizophrenia is brought to the emergency department. The patient is agitated and demonstrates generalized muscle rigidity. Temperature, heart rate, and respiratory rate are elevated. These assessment findings are consistent with which of the following adverse effects of antipsychotic medication?

Neuroleptic malignant syndrome

Several days after being admitted for depression, the man is sitting there alone and has not finished his meal. Which of the following nursing measures would be most appropriate?

Order small frequent meals

A nurse plans the care for a client receiving ECT. Which of the following options would the nurse perform after the treatment?

Orient the client to the time and place

A veteran of the Iraq war diagnosed with PTSD. Which of the following therapeutic regimens would be most appropriately ordered for this person?

Paroxetine and group therapy

A newly admitted client diagnosed with PTSD. Which behavioral symptoms will the nurse NOT expect the client to experience?

Participation in significant activities

A client denies suicidal ideation comes into the emergency department complaining of insomnia, anhedonia, anorexia, and depressed mood. Which intervention would the nurse implement first?

Perform a thorough physical assessment

A client in an inpatient psychiatric unit refuses to take medication because the pill may have a special coding on it that makes it poisonous. What type of delusion is the client experiencing?

Persecutory delusion (NOT SOMATIC!)

A client diagnosed with bipolar disorder experiencing manic episodes is newly admitted to the inpatient psychiatric unit. Which nursing diagnosis is most related to physical violence?

Poor impulse control

A client in the inpatient psychiatric unit is experiencing a flashback. Which intervention takes priority?

Reassure the client of his or her safety

Which of the following nursing interventions assist the client experiencing bothersome hallucinations to adhere to medication compliance?

Remind this client that the medication helps the hallucination

A child diagnosed with autistic disorder makes no eye contact and is unresponsive when talking with the staff members. He bangs his head. Which diagnosis would take priority?

Risk for injury related to head banging

A client diagnosed with major depressive disorder is admitted to the inpatient psychiatric unit. The client's history is 2 suicide attempts by hanging. Which nursing diagnosis takes priority?

Risk for suicide: history of attempts

A newly admitted client diagnosed with PTSD is experiencing recurrent flashbacks, nightmares, food deprivation, and isolation from others. Which nursing diagnosis takes priority.

Risk of injury related to exhaustion because of sustained levels of anxiety

A client is experiencing auditory hallucinations and a flight of ideas. Which medication has these side effects?

Risperdal

A newly admitted client has started taking bupropion (Buspur). The nurse monitors which of the following side effects that would indicate an overdosage of the medication?

Seizure

When planning care for a client hospitalized with depression, the nurse includes measures to increase the client's self esteem. Which of the following actions should the nurse take to meet this goal?

Set simple, realistic goals with him to help him experience success

Which of the following would the nurse expect to assess in fetishism?

Sexual arousal and fantasies involving nonanimate objects

The inability to maintain the physiologic requirements in sexual intercourse is...

Sexual arousal disorder

The nurse is caring for a woman who states she was beaten and sexually assaulted by a male friend. Which of the following should the nurse do first?

Stay with the client during the physical exam

The nurse is caring for a woman who states she's been beaten and sexually assaulted by a male friend. Which of the following would the nurse do FIRST?

Stay with the client during the physical examination

The ingestion of a small amount of drugs would be considered to be a...

Suicidal gesture (NOT THREAT)

A client diagnosed with PTSD says to the nurse, "all those wonderful people died, and yet I was allowed to live." What is the client experiencing?

Survivor's guilt

A 65 year old with a history of prostitution is seen in the emergency department is experiencing a recent onset of auditory hallucinations and bizarre behaviors. Which diagnosis would the nurse expect?

Tertiary Syphilis

A nurse is planning to teach about proper coping skills. The nurse would expect which client has the highest level of readiness to participate?

The client admitted 6 days ago with suicidal ideation

A 21-year-old client being treated for asthma with steroid medication has been experiencing delusions of persecution and disorganized thinking for the past 6 months. Which factor may rule out a diagnosis of schizophrenia?

The client is receiving a medication that can lead to thought disturbances

A client entered the inpatient psychiatric unit a week ago and is under treatment observation. He suddenly appears cheerful. The nurse should be aware of which of the following?

The client may have finalized a suicide plan

Which outcome should the nurse expect from a client diagnosed with schizophrenia who's hearing and seeing things others do not see?

The client will recognize distortions of reality by discharge.

A client hospitalized with PTSD would have a nursing diagnosis to ineffective coping related to history of rape as evidence of abusing alcohol. Which is expected as a short term outcome for the client?

The client will recognize triggers that precipitate alcohol abuse by day 2

The client's diagnosis of risk for suicide, due to past suicide attempts. Which outcome based on this diagnosis would the nurse prioritize?

The client will remain free from injuries throughout hospitalization

A client identifying as homosexual is discussing social orientation. Which client statement is true relating to this concept?

The psychiatric community does not consider homosexuality to be a mental disturbance

Which of the following may be influential in the predisposition to PTSD?

The severity of the stress and the availability of support systems

A nursing instructor is teaching about the etiology of schizophrenia. What statement by the nursing student indicates an understanding of the content presented?

There are a lot of potential causes for this disease, and this continues to be a controversial topic.

After 2 weeks of lithium therapy, a client in the psychiatric unit becomes depressed. Which of the following evaluations of the client's behavior by the nurse would be most accurate?

This is a normal response to lithium therapy; the client should be monitored for suicidal behavior

Which of the following side effects are not associated with tricyclics?

Urinary incontinence

A student nurse tells her instructor that she is scared to care for mental health patients because they are violent. Which statement would the instructor use to clarify the perception of the student?

Very few clients with mental illness exhibit dangerous behavior

Which situation does a healthcare worker have a duty to warn the potential victim?

When the client makes specific threats towards someone who is identifiable

A client with depression is taking phenelzine (Nardil). The nurse advises the client to avoid consuming which foods while taking the medication?

Yogurt

A client admitted into the inpatient psychiatric unit diagnosed with major depressive disorder. Which of the following data would the nurse expect to assess. Select all that apply

a. A loss of interest in almost all activities b. Anhedonia (a lack of pleasure) c. A change of 5% body weight in a month d. Psychomotor retardation or agitation

A homeless client being seen in the mental health unit complains of an infestation of insects on the skin. Which intervention would the nurse implement first? a. Check the client's body for lice b. Present reality regarding somatic delusions c. Refer for inpatient care

a. Check the client's body for lice

Which of the following does the nurse expect to assess in a client with PTSD? Select all that apply.

a. Dissociative events b. Feelings of helplessness c. Avoids activities associated with the trauma

When caring for a patient during an acute panic attack, which of the following actions by the healthcare provider is most appropriate? a. Offer the patient reassurance of safety and security. b. Explore common phobias associated with panic attacks. c. Ask open ended questions to encourage communication. d. Use distraction techniques to change the patient's focus.

a. Offer the patient reassurance of safety and security.

A former client calls the psychiatric unit expressing suicidal thoughts. Which action taken by the registered nurse would NOT be necessary? a. Assess the validity of the call. b. Persuade the client to take their medication. c. Express genuine concern. d. Obtain the caller's name, telephone number, and address of whereabouts

b. Persuade the client to take their medication.

A patient diagnosed with general anxiety disorder (GAD) reports ongoing nausea and abdominal bloating. A physical examination fails to confirm a medical illness to explain these symptoms. The HCP suspects these findings are a result of which of the following? a. Dysthymia. b. Dissociation. c. Somatization (soma means body). d. Derealization.

c. Somatization (soma means body).

The nurse is interviewing a client that is being treated for OCD. Which of the following is the most important question the nurse should ask? a. do you find yourself forgetting simple things? b. do you find it hard to stay on task? c. do you find trouble controlling upsetting thoughts? d. do you experience feelings of panic in a closed area?

c. do you find trouble controlling upsetting thoughts?

A man is admitted to a psychiatric unit with a diagnosis of OCD. He is unable to stay employed because of his ritualistic behavior causes him to be late for work. Which of the following interpretations of the client's behavior, by the nurse, is most accurate? a. he is responding to auditory hallucinations and trying to gain control over his behavior b. he is fulfilling an unconscious desire to kill himself c. he is attempting to reduce anxiety by taking control of his environment d. he is mali

c. he is attempting to reduce anxiety by taking control of his environment

A patient diagnosed with OCD continually carries a toothbrush, and will brush and floss up to fifty times each day. The HCP understands that the pt behavior is an attempt to a. avoid interacting with others b. promote oral health c. relieve anxiety d. experience pleasure

c. relieve anxiety

A pt is receiving care after being diagnosed with GAD. Which of these statements made by the pt indicate to the HCP that the pt is beginning to show signs of improvement? a. "Situations that can cause anxiety can always be avoided." b. "Now I know that my anxiety is caused by a lack of sleep." c. "As long as I can take my medication, I can deal with anxiety." d. "I can tell when I'm beginning to experience anxiety."

d. "I can tell when I'm beginning to experience anxiety."

A patient is diagnosed with agoraphobia. Which of the following would the healthcare identify as a characteristic of this disorder? a. avoids being in the presence of clowns b. avoids interacting with strangers c. refuses to use a public restroom d. fears the use of public transportation

d. fears the use of public transportation

The nurse wants a patient with OCD to come for lunch or talk to someone. When is the best time for a nurse to do something with the patient?

in a relief part of the cycle