Mental Health B

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

Rhinorrhea (The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain.)

A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client diagnosis?

She wont let me take the trash from her room. Im concerned about what she has in there (The client might be binge eating and attempting to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent's statement indicates awareness of the client's behavior.)

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

Stay with a client who has anorexia nervosa for 1 hr after mealtimes (Staying with a client who has anorexia nervosa following mealtimes is within the range of function of an AP. APs are allowed to attend to the safety of clients who are stable, and this task does not require assessment or technical skill.)

A nurse in mental health clinic is caring for a client who has post-traumatic stress disorder after returning form military deployment. Which of the following is the priority action for the nurse to take?

Stay with the client when flashbacks occur

A nurse is talking with a group of parent who have recently experience 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 child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as a adverse effect of methylphenidate?

Tachycardia (Weight gain (no no) pt loose weight on this med). (Tinnitus not an adverse effect) (Increased salivation(no no) Dry mouth is an adverse effect)

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 partner indicates an understanding of the teaching?

I will not take charge of my partner work responsibilities (The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities)

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 and understanding of the teaching?

I will update the plan of care as a client manifestations of depression change (The nurse should update the plan of care as a client's status and needs change.)

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

Identify signs of escalation of violence. (It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the first component of the safety plan because it increases awareness of when danger is imminent and it is time to leave.)

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?

offer the client high-calorie finger foods frequently (The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration.)

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

"Clients who are admitted involuntarily maintain the right to give informed concept for procedures" (Clients who are admitted involuntarily maintain the right to give informed consent for treatment. They also have the right to give informed consent for procedures.)

A nurse is assisting a clietn 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 Im unable to walk"

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 feeling with a close friend"

A nurse observes a client on a mental health unit pushing on the locked 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 oder adult client who begins to cry and states, "I knew god would punish me and i deserve this horrible sickness" which response should he nurse make?

"Lets take about what is upsetting you"

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "Im so fat i cant even stand to look at myself" Which of the following therapeutic responses demonstrates the nurse use of summarizing?

"You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."

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

"its important for our child to have regular dental checkups"

Med math

1.5

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

A 35-year-old client who has major depressive disorder (A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent.)

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

A client who is experiencing delusion of persecution

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

A client who is taking clozapine and reports a sore throat and chills (When using the urgent vs. nonurgent approach to client care, the nurse should determine to first see the client who is taking clozapine and reports a sore throat and chills. Clozapine can cause agranulocytosis, a serious adverse effect that causes neutropenia. The nurse should withhold the medication and notify the provider of these findings.)

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the groups time. Which of the following interventions should the nurse implement?

Ask group members to discuss their feeling about this clients monopolizing behavior

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

Acute dystonia (The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.)

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 bed-bound and has a stage IV pressure ulcer (A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.)

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurese include in the teaching?

Apply restraints when other means of managing the clients behavior have failed (According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints.)

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 the home?

Assertive community treatment (Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.)

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Assist the client with deep breathing exercises. (Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.)

A nurse on medical surgical unit is assessing a client who sustained injuries 12 hrs ago following a motor vehicle crash. The clients admission blood alcohol level was 32. which of the findings should indicate to the nurse that the client is experiencing alcohol with drawls?

Blood pressure (Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever.)

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

Call for a team staff members to help with the situation (The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.)

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

Ill stay with you just in case you want to talk (This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings.)

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include?

Early identification of changes, such as decreased social involvement, is important (Decreased social involvement is a manifestation of depression, and early identification of findings can lead to early intervention.)

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 findings supports the nurse suspicion of delirium?

Easily distracted (extreme distractibility is a hollmark manifestation of delirium)

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 in a community health center is teaching families of clients who have PTSD about expected clinical manifestations. Which of the following manifestations should the nurse include?

Experiences feeling of isolation (The nurse should expect clients who have PTSD to feel estranged and detached from others.)

A nurse is preparing to participate in a interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team.

Giving away possessions

A nurse is assessing a client who has major depressive disorder and has been reviving amitriptyline for 1 week. Which of the following outcomes should the nurse expect?

Greater risk of attempting suicide as affect and energy improve (The nurse should identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a plan is increased after 1 week of treatment.)

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 caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?

Increased creatine phosphokinase (CPK) (An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy)

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

Inform the client that this admission is confidential

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post -traumatic stress disorder?

Lack of interest in an upcoming holiday

A nurse is education 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 (The nurse should identify that language delays are a manifestation of autism spectrum disorder.)

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

Mild (The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information.)

A nurse is planning care for a client who is to undergo ECT. Which of the following actions should the nurse include in the planb?

Monitor the clients cardiac rhythm during the procedure

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has sever depression. The client who has depression reports to the nurse, "My roommate never sleeps and keep me up too" 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 threats towards others on the unit. Although the client does not want to leave the unit, the nurse requests 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 this situation?

Nonmaleficence (do no harm)

A nurse is preparing to discharge to home an 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 is correct. An occupational therapist can assist the client to perform ADLs. Meal delivery services is correct. Meal delivery services are necessary due to the client's difficulty performing ADLs. Speech-language pathologist is incorrect. There is no indication that the client needs a referral for a speech-language pathologist. This referral would be indicated if the client had difficulty swallowing. Physical therapy is correct. A physical therapist can assess the client's mobility needs and assist with ADLs.Home health services is correct. Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs.

A nurse is assessing a family 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 medications that the client reports taking alert the nurse to potential adverse reactions?

Phenylephrine (Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.)

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

Reduce environmental stimuli (The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.)

A nurse is crating a plan of care fo r a client who has been placed on seclusion after threatening to harm others on the unit. which of the following interventions should the nurse include in the plan?

Renew the prescription for the client every 4 hr (The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.)

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 (The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression.)

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

The client should obtain a sponsor before discharge for an increased change of recovery.

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 contraindication for receiving clozapine?

WBC 2500/mm3 (Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.)

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

use a screening tool to evaluate the client for depression

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

Identify the clients trigger foods (The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.)

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

Inability to sleep