Mental Health B

A charge nurse on a mental health unit is discussing client rides with the newly licensed nurse. Which of the following statements should the charge nurse make?

"Clients were admitted, involuntarily maintain the right to give informed consent for procedures."

A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness?

"I am going to order a wheelchair for when I'm unable to walk."

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the clients partner indicates an understanding of teaching?

"I will not take charge of my partner's work responsibilities."

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching?

"I will talk about my feelings with a close friend."

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will update the plan of care as a clients manifestations of depression change"

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statement should the nurse make?

"I'll stay with you just in case you want to talk"

A nurse observes a client on a mental health Unit pushing on the lock unit door. Which of the following statements should the nurse make?

"It appears as though you would like to open the door"

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me, and I deserve this horrible sickness!" Which of the following responses should the nurse make?

"Let's talk about what's upsetting you"

A nurse is preparing to administer diazepam, 7.5 mg IV. Bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer?

7.5mg / 5mg = 1.5mL

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can get informed consent?

A 35 year old client who has major depressive disorder

A nurse on an acute mental health facility is receiving change of shift report for four clients. Which of the following client should the nurse assess first?

A client who is experiencing delusions of persecution

A nurse is receiving change-of-shift report for four clients. Which of the following client should the nurse plan to see first?

A client who is taking clozapine and report, sore throat and chills

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse?

An older adult client who is bedbound and has a stage IV pressure ulcer.

A nurse is caring for a client who has a personality disorder. For each potential nursing intervention click to specify if the potential intervention is anticipated, nonessential are contraindicated for the client.

Anticipated • haloperidol 2 mg IM • approach the client and state "you seem agitated. Let's sit quietly and talk about it" Nonessential • Request change of diet to mechanical soft Contraindicated • hold the next dose of buspar • Request prescription for digoxin 1 mg IV bolus stat

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?

Assertive community treatment

A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hr ago following a motor vehicle crash. The clients admission blood alcohol level was 325 mg/dL. Which of the following finding should indicate to the nurse that the client is experiencing alcohol withdrawal?

Blood pressure 154/96

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following action should the nurse take first?

Call a team of staff members to help with the situation.

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others?

Command hallucinations

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment finding supports the nurses suspicion of delirium?

Easily distracted -Extreme distractibility is a hallmark manifestation of delirium.

A nurse is caring for a client who is an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?

Identify signs of escalation of violence.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

Establish screening programs to identify at-risk clients.

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for one week. Which of the following outcomes should the nurse expect?

Greater risk of attempting suicide as affect an energy improve

A nurse is caring for a client who has a personality disorder major depressive disorder, and borderline personality disorder

Improved • client verbalizes precipitating factors to violent outburst • client follow the instructions of the nurse No change • client is silent and glaring at staff Declined • client attempts to bite nursing staff when offered water

A nurse is reviewing a clients medical record. For each assessment, finding click to specify of the finding is an improvement no change or decline in the clients condition.

Improvement • pain level • Vital signs • Daytime orientation • I&O No change • Sleep wake cycle • glucose level Decline • ambulatuon

A nurse is teaching a partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider?

Inability to sleep

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse client relationship which of the following action, should the nurse take first?

Inform the client that this admission is confidential

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

language delay

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety, should the nurse plan to teach the client relaxation techniques?

Mild -this is when the client will be able to concentrate and process information

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "my roommate never sleeps, and keeps me up, two". Which of the following action should the nurse take?

Move the client who has bipolar disorder to a private room

A nurse is planning care for a client who has made repeated physical threat towards others on the unit. Although the client does not want to leave the unit, the nurse request the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in the situation?

Nonmaleficence

A nurse is caring for a client who has a personality disorder. For each potential providers prescription, click to specify if the prescribe therapy is expected with obsessive compulsive disorder dementia, or borderline personality disorder.

OCD •systematic desensitization •Fluoxetine 20 mg PO daily Dementia • Validation therapy • donepezil 5 mg PO daily Borderline personality disorder •dialectical behavioral therapy • Fluoxetine 20 mg PO daily

A nurse is assessing a family's dynamic during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?

Older children who are responsible for their younger siblings

A nurse is caring for an older adult client who is experiencing delirium. Which of the following intervention should the nurse include in the clients plan of care?

Permit the client to perform daily rituals to decrease anxiety.

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over the counter medication's that the client reports taking should alert the nurse to a potential adverse reaction?

Phenylephrine

A nurse is caring for a child who has conduct disorder, and he's behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority?

Reduce environmental stimuli

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following intervention should the nurse include in the plan?

Renew the prescription for the client every four hours (for a maximum of 24 hours)

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?

Spending adequate time with a client who is verbally abusive.

A nurse in a mental health clinic is planning care for four clients. Which of the following tasks are the nurse delegate to an assistive personnel?

Stay with a client who has anorexia nervosa for one hour after meal times

A nurse is caring for a child who is taking methylphenidate. The nurse and monitor the child for which of the following findings as an adverse effect of methylphenidate?

Tachycardia

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?

The client has COPD

A nurse is discussing a 12 step program with a client who has alcohol use disorder and is in an acute care facility undergoing detox vacation. Which of the following information should the nurse include in the teaching?

The client should obtain a sponsor before discharge for an increase chance of recovery

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?

Tooth erosion

A nurse at a providers office is interviewing an older adult client. Which of the following action should the nurse plan to take?

Use a screening tool to evaluate the client for depression

A nurse is caring for a client who has a personality disorder. Complete the sentence by using the list of options. The client is at risk for ____ as evidence by the clients____

Violent behavior Increased agitation

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contra indication for receiving clozapine?

WBC count 2,500/mm³

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects?

acute dystonia

A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following intervention should the nurse include to reduce anxiety among the group members?

guided imagery

A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. Which of the following findings should the nurse report to the provider immediately?

• Blood pressure • I&O • Temperature • Sleep wake cycle • cognitive awareness

A nurse is caring for a client who has anorexia nervosa. A nurse is evaluating the client after two weeks. Which of the following findings indicate an improvement in the clients condition?

• Skin temperature • heart rate • Potassium • sodium • BUN • bowel movement • BMI

A nurse is caring for a client who has a personality disorder. Major depressive disorder, borderline personality disorder. Select the six findings found in the clients medical record that are manifestations of the client diagnosed personality disorder.

• hyper sexualization • stealing money from family to cover credit card charges • married multiple times • incidences of self injury • physical altercations • anxious, if left alone

A nurse is caring for a client who is experiencing delirium. The nurse should first ____ followed by____

• initiate IV fluids • administering acetaminophen

A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event. The nurse is providing teaching to the client. Which of the following statements should the nurse include in the teaching?

" you should seek help if you have thoughts of self harm" " it is common for people who survived a traumatic event to experience feelings of." " a support group might be helpful to you during this time."

A nurse is teaching the guardians of a client about their adolescent child diagnosis of bulimia nervosa. Which of the following statements made by the guardians, indicates an understanding of their child's illness?

"It is important for a child to have regular dental, check ups"

A nurse is assessing an older adult client, who is postoperative following a right knee arthroplasty. For each potential providers prescription click to specify if the potential prescription is anticipated, nonessential, or contraindicated.

Anticipated • urinalysis with culture and sensitivity • Melatonin • IV fluids Nonessential • MRI of the head Contra indicated • apply restraints • Insert indwelling urinary catheter

A nurse is updating the plan of care for a client who has bulimia nervosa and it's 5% above their ideal body weight. Which of the following intervention should the nurse include in the plan?

Identify the client's trigger foods

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

Suggest forming a weekly support group for parents who have experienced the death of a child.

A nurse is caring for a client who has a personality disorder. Which of the following action should the nurse take? Major depressive disorder and borderline personality disorder.

• maintain continuous observation of the client wall in restraints • conduct debriefing with a client and other staff

A nurse is caring for a client who is experiencing delirium. Which of the following action should the nurse take for this client?

• offer the client warm milk at bedtime • Maintain a low stimulation environment • Approach the client from the front and speak slowly

A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. Which of the following information from the clients medical record our risk factors for delirium?

• postoperative • fever • clients age • hospital environment

A nurse is preparing to discharge to home and older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate?

•Occupational therapy • meal delivery services • physical therapy • home health services