Mental Health Exam 1

a client is newly diagnosed with 4th stage NCD due to Alzheimer's disease. Which cognitive change is indicative of stage 4 NCD due to AD? (Select all that apply) 1) Lost memory of personal history 2) trouble handling bills or traveling 3) inability to count backwards 4) decreased awareness of current or recent events 5) reduced expression or emotions

1) Lost memory of personal history 2) trouble handling bills or traveling 3) inability to count backwards 4) decreased awareness of current or recent events 5) reduced expression or emotions

A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic? 1) "Everyone feels better after showering" 2) "You must be getting better. You look great!" 3) "I see you have done some grooming today." 4) "Why are you all dressed up today? Is it a special occasion?"

3) "I see you have done some grooming today"

Which finding depicts negative symptoms of schizophrenia? 1) difficulty standing still 2) rapid and disorganized speech 3) flat affect and social inattentiveness 4) delusional statements

3) flat affect and social inattentiveness

which of the following nursing interventions is appropriate for a client with a NCD and a nursing diagnosis of disturbed sensory perception?

Provide distractions for the client. Focus on real situations and real people.

A nurse is reviewing abnormal laboratory values for four clients who has schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued? 1) a client who has a WBC of 2,900 cells/mm3 2) a client who has a hematocrit of 55% 3) a client who has a serum potassium of 3.3 mEq/L 4) a client who has a BUN of 22 mg/dL

1) a client who has a WBC of 2,900 cells/mm3

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client? 1) a private room in a quiet location on the unit 2) a semi-private room with a roommate who has a similar diagnosis 3) a private room close to the nursing station 4) a seclusion room until the client's activity level becomes more subdued

1) a private room in a quiet location on the unit

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom? 1) affective flattening 2) bizarre behavior 3) illogicality 4) somatic delusions

1) affective flattening

a nurse in the emergency department is preparing to care for a client who has signs of alcohol intoxication. Which of the following should the nurse plan to include in the client's care? Select all that apply. 1) contact the laboratory to obtain a blood sample 2) prepare the client for a CT scan 3) check the client's pupil reactivity 4) obtain a urine specimen

1) contact the laboratory to obtain a blood sample 2) prepare the client for a CT scan 3) check the client's pupil reactivity 4) obtain a urine specimen

A nurse is caring for a client who has severe s/s of schizoid and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? 1) dysrhythmias 2) cataracts 3) pancreatitis 4) bleeding

1) dysrhythmias

a nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for Lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity? 1) experiencing diarrhea 2) exercising moderately 3) increasing sodium intake 4) drinking green tea

1) experiencing diarrhea

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the nurse should the nurse interpret as displaying manic behavior? (Select all that apply) 1) talking in rapid, continuous speech 2) interacting with others in a flirtatious way 3) spending large sums of money 4) sleeping for long periods of time 5) dressing in black or grey clothing

1) talking in rapid, continuous speech 2) interacting with others in a flirtatious way 3) spending large sums of money

A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of teh following information should the nurse include in the teaching? 1) temporary memory loss is the most common adverse affect of ECT 2) medications are given to prevent seizure activity during ECT 3)the greatest risk of ECT is brain damage 4) ECT is effective in the treament of substance use disorders

1) temporary memory loss is the most common adverse effect of ECT

a nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. Which of the following statements by the clients indicate adaptive coping? (select all that apply) 1) "I exercise aerobically three times a day for 30 minutes at a time." 2) "I get 7 hours of sleep at night by skipping afternoon naps." 3) "I think about being on my favorite beach vacation when I get anxious." 4) "I tense and release my muscles, starting with my feet." 5) "I see the glass as half-full when it starts looking empty."

2) "I get 7 hours of sleep at night by skipping afternoon naps." 3) "I think about being on my favorite beach vacation when I get anxious." 4) "I tense and release my muscles, starting with my feet." 5) "I see the glass as half-full when it starts looking empty."

A nurse is teaching a client who plans to take St. John's Wort to treat her depression. Which of the following information should the nurse include in the teaching? 1) "You should avoid driving when taking St. John's wort because it can cause dizziness." 2) "You may experience vivid dreams while taking St. John's wort." 3) "St. John's Wort may increase risk for developing oxalate kidney stones." 4) "St. John's wort may cause GI irritation."

2) "You may experience vivid dreams while taking St. John's Wort."

A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make? 1) "You are mistaken. Nobody is lying about you or trying to poison you." 2) "You seem to be having very frightening thoughts." 3) "Why do you think you are being lied about and poisoned?" 4) "Who is lying about you and trying to poison you?"

2) "You seem to be having very frightening thoughts."

A nurse is caring for a client who has bipolar disorder. The client states, "I feel like superman. I can do anything. I can fly home today and then become a U.S. senator." Which of the following findings is this client exhibiting? 1) flight of ideas 2) grandiosity 3) reality testing 4) derealization

2) grandiosity

a nurse is providing teaching for a client who has schizophrenia and a new prescription for fluphenazine. Which of the following information should the nurse provide? 1) this med might turn your urine orange 2) sleepiness should subside within a week 3) stop the medication if hypotension occurs 4) a low-grade fever is expected with first doses

2) sleepiness should subside within a week

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activites is appropriate for the nurse to suggest to this client? 1) watching a video with a group in the day room 2) walking with the nurse in the courtyard 3) participating in a basketball game in the gym 4) joining a group discussion about a local election

2) walking with the nurse in the courtyard

a nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts? 1) "I am responsible for my alcoholism." 2) "I need to identify things that cause me to be an alcoholic." 3) "I am powerless against my addiction to alcohol." 4) "I need to see a counselor who will be responsible for my recovery."

3) "I am powerless against my addiction to alcohol."

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activies, or participate in any of the unit's programs. Which of the following responses should the nurse make? 1) "you really need to follow the rules of the unit and get out of bed." 2) "if you do not get out of bed you will not receive your meal." 3) "I will help you get ready and then you can rest after activities" 4) "You should rest until you feel able to join the group"

3) "I will help you get ready and then you can rest after activities"

a nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the following statements by the client indicates understanding of the teaching? 1) I should expect relief from depression within 3-4 days 2) I will take my fluoxetine at bedtime so I can sleep better 3) I should notify my provider if I develop a skin rash 4) I will notice an improvement in my sex drive

3) I should notify my provider if I develop a skin rash

A nurse is reviewing the medical record of a client who has a prescription for Clozapine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to Clozapine? 1) asthma 2) fasting blood glucose 120 mg/dL 3) WBC count 3,300/mm3 4) hypertension

3) WBC count 3,300/mm3

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take? 1) act to the client as if the hallucination is real 2) instruct the client to argue with the voices that are a part of the hallucination 3) ask the client direct questions about the hallucination 4) tell the client that the hallucination is not a part of reality

3) ask the client direct questions about the hallucination

A nurse is caring for a client following a suicide attempt. The client has a history of depression, subtance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority? 1) reviewing the client's toxicology laboratory report 2) making a. contract with the client for the eating behavior 3) initiating suicide precautions 4) administering the Hamilton Depression Scale

3) initiating suicide precautions

A client who has bipolar disoerder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first? 1) implement the client's behavioral modification plan 2) document the size and location of the cuts 3) inspect the cuts for debris 4) administer a tetanus antitoxin

3) inspect the cuts for debris

a nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? 1) provide a cognitively stimulating environment 2) rotate staff to prevent caregiver role strain 3) limit the client's choices for daily activities 4) use confrontation to manage negative behavior

3) limit the client's choices for daily activities

a nurse is caring for a client who has bipolar disorder and a new prescription got Valproate. Which of the following instructions should the nurse give the client about the use of this medication? 1) thyroid function tests should be performed every 6 months 2) a pretreatment electroencephalogram (EEG) will be done 3) liver function tests must be monitored 4) high serum sodium levels can cause toxic levels of Valproete

3) liver function tests must be monitored

A nurse in an acute mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed andthere are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?" 1) encourage family to take the client out of the facility for short periods of time 2) reward the client for her change in behavior 3) monitor the client's wherabouts at all times 4) ask the client why her behavior has changed

3) monitor the client's wherabouts at all times

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The flakalas are here. The flakalas are here." The nurse correctly recognizes the client's use of the word flakala as an example of which of the following alterations in speech? 1) echolalia 2) clang association 3) neologism 4) word salad

3) neologism

A nurse in an acute mental health facility to assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide? 1) the client has begun playing basketball with several other clients during the past month 2) the client identifies with problems expressed by other clients 3) the client's behavior has become impulsive in the past few weeks 4) the client states that she wants to go home to be with her children and partner

3) the client's behavior has become impulsive in the past few weeks

A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression? 1) being married 2) pregnancy 3) male gender 4) chronic illness

4) chronic illness

a nurse us caring for a client who has a recent diagnosis of alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect manifestations to occur first? 1) inability to recognize family members 2) chooses clothing that is inappropriate for the weather 3) exhibits a change in personality 4) frequently misplaces objects

4) frequently misplaces objects

A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care? 1) discourage rest periods during the daytime 2)instruct family to avoid visiting during mealtimes 3) offer 3 or 4 large meals/day 4) give the client extra time to communicate needs

4) give the client extra time to communicate needs

A nurse is caring for a client who is receiving treatment of alcohol withdrawal. Which of the following findings is the highest priority? 1) vitamin deficiency 2) diaphoresis 3) increased heart rate 4) illusions

4) illusions

A nurse is planning care for a patient who is to undergo electroconvulsive therapy (ECT). Which actions should be included in the plan of care? 1) administer Phenytoin 30 min prior to the procedure 2) instruct the client to expect a headache following the procedure 3) place the client in four point restraints prior to the procedure 4) monitor the client's cardiac rhythm during the procedure

4) monitor the client's cardiac rhythm during the procedure

The nurse understands that schizophrenia can be differentiated from psychosis by which assessment? 1) disorganized speech 2) disorganized behavior 3) auditory hallucinations 4) negative symptoms

4) negative symptoms

A nurse is caring for a client who is hospitalized for treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care? 1) encouraging decision-making 2) giving the client choices of activities 3) playing a game of chess with the client 4) spending time sitting with the client

4) spending time sitting with the client

The nurse is providing discharge teaching for a client who has bipolar disorder and will be discharged with a script for lithium. The nurse should teach the client that which of the following factors puts the client at risk for lithium toxicity? 1) the client eats food high in Tyramine 2) the client eats 2-3 grams of sodium containing food daily 3) the client drinks 2 liters of liquid daily 4) the client runs 4 miles outdoors every afternoon

4) the client runs 4 miles outdoors every afternoon