Mental health CMS

A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse. "This baby constantly cries. My partner works all the time, and I can't take any more." Which of the following responses is the nurse's priority? "Tell me about your baby. Where is she now?" Have you discussed this with your partner?" "Do you have a friend who could help you?" "Having a newborn must be stressful. Do you have other children?

"Having a newborn must be stressful. Do you have other children?

A nurse is collecting data from the parents of a child who recently began treatment for ADHD with methylphenidate. Which of the following statements indicates that the child might have developed an adverse effect to the medication? "He doesn't seem to sleep well at night." "He has been frequently interrupting others." "He seems to get distracted very easily." "He has to fidget constantly with something."

"He doesn't seem to sleep well at night."

A nurse is caring for a client who has dementia and asks to see her partner, who died several years ago. Which of the following responses should the nurse make when using validation therapy? "You know your partner died many years ago." "Let's talk about your partner's death." "Let's take a walk. We can look for your partner." "I am sure you miss your partner"

"I am sure you miss your partner"

A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination? Can you see these spiders crawling all over me?' "Are you planning to kill me?" The aliens are going to abduct me tonight." "The voices told me to quit eating the food here."

"The voices told me to quit eating the food here."

A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep? You should take a nap after lunch." You should drink a glass of wine 1 hour before you go to bed." You should eat a meal just prior to bedtime." "You should limit yourself to two caffeinated beverages per day."

"You should limit yourself to two caffeinated beverages per day."

A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first? A client who is repeatedly approaching the nurses' station to request medication for his anxiety A client in the dayroom who is screaming at other clients about what is on the television A client who is standing in her room, yelling obscenities and throwing her clothes A client who has bipolar disorder and is continuously pacing at the end of the hall

A client who has bipolar disorder and is continuously pacing at the end of the hall

A nurse in an urgent care facility is collecting data from a group of clients. The nurse should identify that which of the following clients is at risk for experiencing a maturational crisis? A client who was sexually assaulted A client who is in the process of getting a divorce A client who recently retired from a longtime job A client who lost her home in a fire

A client who recently retired from a longtime job

A nurse on an inpatient mental health unit is caring for a client who has bipolar disorder. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate catetorles of data.) initiate sodium restrictions. Engage the client in a group activity. Withnoid the next dose of aripiprazol Accompany the client to a private area.

Accompany the client to a private area.

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder? Agree to a prescription for an alcohol use deterrent. Form a close support network. Incorporate a form of spirituality into daily life. Acknowledge an inability to control drinking.

Acknowledge an inability to control drinking

A nurse is caring for a client who states, "I'm overwhelmed, and no one understands. I can't take it anymore." Which of the following responses should the nurse make first? "Do you have anyone you can talk to about your feelings?" "Are you saying that no one understands your concerns?" "Are you thinking of harming yourself?" Tell me more about how you are feeling"

Are you thinking of harming yourself?"

A nurse is assisting with screenings for child abuse at a preschool. Which of the following factors place a child at risk for abuse? Acute bronchitis Bedwetting First-born child Autism spectrum disorder

Autism spectrum disorder

A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use? Be vague when answering the client's questions about instructions. Use an overly friendly approach. Demonstrate a neutral demeanor. Ask the client why he is suspicious of others.

Be vague when answering the client's questions about instructions.

A nurse is caring for several clients on an inpatient mental health unit. Which of the following actions demonstrates that the nurse is following the ethical principle of veracity? Providing high-quality care for a client regardless of his personal background Respecting a client's right to refuse to take her medication Being honest with a client about his plan of care Spending extra time with a client who has difficulty sharing her thoughts

Being honest with a client about his plan of care

A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings? Asthma Renal colic Crohns disease Cardiac arrhythmia

Cardiac arrhythmia

A nurse in an acute care mental health facility is assigned to care for a group of clients. Which of the following tasks is the nurse's priority? Accompany a client who has obsessive compulsive disorder to their group therapy session. Complete an Abnormal Involuntary Movement Scale for a client who takes risperidone and is concerned about adverse effects. Check the vital signs of a client who takes phenelzine and ate their roommate's cheese and salami. Talk to a client who has depressive disorder about their past coping strategles.

Check the vital signs of a client who takes phenelzine and ate their roommate's cheese and salami

A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider? Hypoactive bowel sounds in all four quadrants client report of dry mouth Client report of photosensitivity Constant opening and closing of mouth

Constant opening and closing of mouth

A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take to intervene for manipulative behaviors during group therapy? Ignore manipulative behaviors during the session. Discuss consequences of inappropriate behaviors. Bargain with the client regarding established behavioral expectations. Place the client in seclusion immediately after inappropriate behavior occurs.

Discuss consequences of inappropriate behaviors

A client in a mental health facility says to a nurse, "My family won't let me come home if I cannot control my anger." Which of the following responses should the nurse make? Tell me about some changes you can make to control your anger." "I understand your family's feelings regarding your anger." Why do you think your family feels that your anger is a concern?" Do you feel that your medication is helping to control your anger?"

Do you feel that your medication is helping to control your anger?"

A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take? Restrict interactions with other clients. Document the client's behavior every 2 hr. implement 24-hr one-to-one nursing observation. Administer prescribed medication via the IM route.

Document the client's behavior every 2 hr.

A nurse is assisting with a staff education session about legal issues affecting the care of clients who have mental health diagnoses. Which of the following examples should the nurse identify as libel? Taking the clothes of a client who is Voluntarily admitted so that he cannot leave Threatening to apply restraints on a client who is refusing medication Documenting false information about a clients substance use history Administering an incorrect dosage of a client's medication

Documenting false information about a clients substance use history

A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship? Establish a regular meeting time with the client. Collect data about the clients current health status. Determine whether the client's goals are met. Provide the client with information on problem-solving.

Establish a regular meeting time with the client.

A nurse is contributing to the plan of care for a client who experiences panic attacks. Which of the following strategies should be included for implementation during an attack? Explore with the chent what precipitates an attack. Minimize environmental stimuli. Assist the client with evaluating their coping mechanisms. Encourage the client to set goals.

Explore with the client what precipitates an attack.

A nurse is caring for a newly admitted client who has schizophrenia and hearing loss. Which of the following actions should the nurse take first when communicating with the client? Face the client when speaking so the client can read lips. Evaluate the client's understanding of the message. Contact a sign-language Interpreter to communicate with the client. Determine how the client prefers to communicate.

Face the client when speaking so the client can read lips

A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium? Demonstrates obsessive behaviors Consistent state of depression Fluctuating level of orientation Family report of gradual memory loss

Fluctuating level of orientation

A nurse is collecting data from a client who has borderline personality disorder. Which of the following findings should the nurse identify as a risk factor for this disorder? Anxiety disorder Recent concussion History of childhood trauma Recent job loss

History of childhood trauma

A nurse is caring for a client who has terminal cancer and is receiving palliative care. Which of the following statements indicates that the client is demonstrating effective coping? I hope to have surgery to cure my cancer." "I need to return to work as soon as my treatment is complete. " I should start making my funerat arrangements." I still believe my cancer will go into remission."

I should start making my funerat arrangements."

A nurse is sitting with a client in the dayroom. The client jumps up and states, "There are snakes coming toward me! " Which of the following responses should the nurse make? "Let's move to a different room to avoid the snakes." What do you usually do when this happens?" I understand that you're seeing snakes, but I don't see any." Would you like to play cards?"

I understand that you're seeing snakes, but I don't see any.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first? Reinforce teaching on the client's use of coping skills. Encourage the client to use personal support systems. Identify if the client has thoughts of self-harm. Assist with a client referral for social services.

Identify if the client has thoughts of self-harm.

A nurse is reinforcing teaching with a client about naltrexone. Which of the following statements by the client indicates an understanding of teaching? If I drink alcohol with this medication. I will experience ringing in my ears. I will not experience alcohol withdrawal If I take this medication. "Taking this medication will reduce my cravings for alcohol." The medication will allow me to gradually decrease my alcohol intake."

If I drink alcohol with this medication. I will experience ringing in my ears.

A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client? Decreased hallucinations Improved mood Reduction in hand tremors Absence of seizures

Improved mood

A nurse is collecting data from a female client who has bulimia nervosa. Which of the following manifestations should the nurse expect? Increased blood pressure Increased number of dental caries Increased bleeding with menstruation increased potassium level

Increased number of dental caries

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) Splitting Lack of empathy Manipulative behaviors Preoccupation with details Impulsiveness

Lack of empathy Manipulative behaviors Impulsiveness

A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care? Keep the client's room dark at night. Limit the client's need to make decisions. Provide a high-stimulation environment for the client Discourage visitation from the client's family.

Limit the client's need to make decisions.

A nurse is caring for a male client who is to begin therapy with valproic acid. Which of the following diagnostic results should the nurse plan to review before administering the first dose? Prostate specific antigen test Liver function tests Chest x-ray Urine culture

Liver function tests

A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of a maturational crisis? A child leaving for college Divorce Loss of job Motor-vehicle crash

Loss of job

A nurse is collecting data from a client who has a new diagnosis of bipolar disorder. Which of the following behaviors supports this diagnosis? Excessive dietary intake Paranoid thinking Ritualistic actions constant talking

Paranoid thinking

A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest? Administer an antianxiety medication before bedtime. Place a lock at the top of doors leading outside. use light restraints whille the client is in bed. Encourage the client to nap during the day.

Place a lock at the top of doors leading outside.

A nurse is reviewing the laboratory results of a client who has anorexia nervosa. Which of the following results should the nurse report to the provider? Potassium 2.8 mEg/L WBC count 6,000/mm O HDA1C 4% Sodium 138 mEg/L

Potassium 2.8 mEg/L

A nurse is observing a newly hired nurse communicate with a client. The newly hired nurse asks. "You take your medications at a different time than prescribed?" Which of the following communication techniques is the newly hired nurse using? Offering self Exploring Presenting reality Reflecting

Presenting reality

A nurse is contributing to the plan of care for a client who is experiencing a panic level of anxiety. Which of the following interventions should the nurse include? (Select all that apply.) Encourage the client to visit with friends. Remain with the client. Speak to the client using a calm tone of voice. Take the dient to a group therapy session. Offer to take a walk with the client.

Remain with the client. Speak to the client using a calm tone of voice. Offer to take a walk with the client

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take? Request the provider renew the prescription in 24 hr. Keep staff interactions with the client to a minimum. Provide range-of-motion exercises to all extremities every 2 hr. Document the client's behavior in the medical record every 1 hr.

Request the provider renew the prescription in 24 hr.

A nurse is caring for a client who has a new prescription for lithium. Which of the following should the nurse monitor during treatment? Oxygen saturation Triglyceride Blood glucose Sodium

Sodium

A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations? Intellectualization. Somatization Reaction formation sublimation

Somatization

A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent? Recelving light therapy Participating in a group exercise program Attending a cognitive behavioral therapy class Taking an experimental medication

Taking an experimental medication

A nurse is on the elevator and overhears two nurses discussing a client on the unit. Which of the following actions should the nurse take? Tell the nurses to stop the discussion. Complete a written warning for each of the nurses. Discuss the occurrence with the cilent. Report the issue to the ethics committee

Tell the nurses to stop the discussion.

A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take? Arrange for the sibling to visit the client in the dayroom. Refer the sibling to the client's provider. Encourage the client to visit with the sibling. Tell the sibling the client does not want visitors.

Tell the sibling the client does not want visitors.

A nurse is collecting data from a client regarding the client's sexual behavior. The client laughs and makes an inappropriate sexual comment. Which of the following is an appropriate response by the nurse? "I am concerned by your response. Can you explain your comment? I don't approve of that comment. We will discuss this later." That is very inappropriate. Why would you say that?" You shouldn't laugh about this. This is a serious topic."

That is very inappropriate. Why would you say that?"

A nurse is caring for a client who has dependent personality disorder. Which of the following findings should the nurse anticipate? The client demonstrates splitting behaviors. The client is comfortable spending time alone. The client monopolizes the discussion in group therapy sessions. The cilent quickly replaces a lost relationship with another.

The cilent quickly replaces a lost relationship with another.

A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective? The client displaces their feelings of self harm until they talk to the provider. The client suppresses their feelings when they are angry. The client notifies the nurse when they want to harm themselves. The client goes to their room alone when they feel overwhelmed.

The client notifies the nurse when they want to harm themselves.

A nurse is collecting data from a client who has severe anxiety and has been using relaxation techniques. Which of the following findings indicates to the nurse that the techniques have been effective? The client's pulse and blood pressure have decreased. The client states that he is using the techniques daily. The client asks the nurse to sit with him for a while. The client sits with his eyes closed for short periods throughout the day.

The client sits with his eyes closed for short periods throughout the day

A nurse is collecting data from an adolescent client who has a conduct disorder. Which of the following findings is the nurse's priority? Lack of empathy for others Repeated school absences Threats of injury to others History of shoplifting

Threats of injury to others

A nurse is monitoring a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of this medication? Urinary retention Hypertension Diarrhea Excessive salivation

Urinary retention

A nurse is reviewing the laboratory findings of a client who is taking clozapine. For which of the following findings should the nurse notify the provider? WBC count 3500mm Sodium 140 mEg/L Platelets 200,000/mm Potassium 3.7 mEc/L

WBC count 3500mm

A nurse is collecting data from a new client. Which of the following questions should the nurse include when determining the client's psychosocial status? "How old were you when you started your menses?" "Do you have medical insurance?" Who do you talk to when you are upset?" When did you last have a mammogram?"

When did you last have a mammogram?"

A nurse is caring for a client who has a psychotic disorder. The client states, "Missing levitation magnet organize fields of devotion complete cross-eye arbitrarily." Which of the following terms should the nurse use when documenting this speech alteration? Word salad clang associations Echolalla Neologisms

Word salad

A nurse in a mental health facility is discussing client rights with an adult client who was involuntarily committed. Which of the following statements should the nurse make? "If you want to leave the hospital, you need to sign a release form." Once 90 days have passed, you can request a review of your admission." Your provider will need to notify your employer of your admission. You have the option to refuse your medication while in the facility."

You have the option to refuse your medication while in the facility."

A nurse is caring for a client who was voluntarily admitted to an acute mental health unit and asks. "You aren't going to make me take medication, are you?" Which of the following responses should the nurse make? You have the right to refuse to take the medication." I can make a list of the medications that you don't want to take." you agreed to take medication when you decided to be admitted." "If the provider prescribes medication, I will have to administer it."

You have the right to refuse to take the medication."

A nurse is visiting the home of a client who has alcohol use disorder. The client smells heavily of alcohol and his clothes are unclean. Which of the following responses should the nurse make? You seem to be having a difficult time." Why aren't you taking better care of yourself?' What would your family think about your drinking?" You should stop drinking and seek treatment."

You seem to be having a difficult time."

A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment? Phenobarbital Chlordiazepoxide buprenorphine Diazepam

buprenorphine

A nurse is caring for a client who has a new diagnosis of cancer. The client states. "I can't think about my health until after my son is married next week." The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms? Reaction formation splitting suppression Projection

suppression