Mental Health Exam 1, psychosocial midterms, Video Case Study Bipolar Disorder, Bipolar Disorders (Psychobiologic Disorders)

cyclothymic disorder

-at least 2 yr of repeated hypomanic manifestations

Bipolar I

-at least one episode of mania/depression

Bipolar II

-one or more episodes

Bipolar disorders

-recurrent mania followed by depression -usually emerge early adulthood -care depends on the phase

s/s of relapse

-substance abuse -sleep disturbances -stressors

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 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 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"

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

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

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

"I'm not comfortable with your comment. I'm here to help you with your problems." If the client makes an inappropriate comment, the nurse should respond in a calm, matter-of-fact tone. The nurse should identify that the comment causes discomfort and then restate the nursing role. This helps maintain boundaries in the therapeutic relationship.

A nurse is caring for a client who has bipolar disorder. The client states, "You are so good looking. Let's go out on a date." Which of the following statements should the nurse make?

Fish sticks with apple slices and a vanilla milkshake. The nurse should offer the client frequent intake of protein, fiber and high-calorie foods and fluids to prevent weight loss, constipation, and exhaustion due to manic behavior. This meal selection meets these dietary needs while providing finger foods that are easy for the client to eat while up and moving around, because it is diffcult for a client experiencing mania to sit down and eat a meal.

A nurse is making dietary selections for a client who is in the manic phase of bipolar disorder. Which of the following choices should the nurse select for the client's lunch?

Clang associations/pressured speech The nurse should expect a client who is in the manic phase of bipolar disorder to exhibit clang associations. This speech pattern is characterized by the client's use of words that rhyme without regard for meaning. The client can also exhibit speech that is rapid, disorganized, and possibly sexually explicit or vulgar.

A nurse is performing an admission assessment for a client who has bipolar disorder and is in the manic phase. Which of the following fndings should the nurse expect?

Muscle weakness The nurse should identify muscle weakness as an early indication of lithium toxicity. Other early indications include diarrhea, nausea and vomiting, polyuria, thirst, lethargy, slurred speech, and tne hand tremors. The nurse should instruct the client and family to withhold lithium and notify the provider if these indicators of toxicity are present.

A nurse is providing discharge teaching with the family of a client who has bipolar disorder and a prescription for lithium. The nurse should identify which of the following findings as an early indication of lithium toxicity?

Promote rest in a quiet environment with decreased client stimulation. The greatest risk to this client is injury and exhaustion resulting from manic behavior due to increased stimulation. Therefore, the priority intervention is to encourage frequent rest periods and sleep in a quiet environment with decreased client stimulation from noise or other clients

A nurse on an acute mental health unit is planning care for a client who has bipolar disorder and is experiencing acute mania. Which of the following interventions should the nurse identify as the priority?

phases (BPD)

ACUTE -hospitalization -reduction of mania -safety mane priority -one on one supervision CONTINUATION -4-9m -relapse prevention MAINTENANCE -tx for life -prevention of mania

a nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. which of the ff responses should the nurse make? a. "why would you want to put your partner's health at further risk?" B. "everyone likes food from home, but it can delay your patient's recovery" c. "you will need to discuss your concerns about your partner's diet with the provider" d. "let's try to find ways to incorporate your partner's favorite food into her diet plan"

B. "everyone likes food from home, but it can delay your patient's recovery"

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 school nurse is speaking to the mother of a 16 yr old male adolescent. the mother has concerns about her son. which of the ff statements by the mother should indicate to the nurse that the adolescent is as risk for suicide? a. "his favorite teacher committed suicide a few weeks ago" b. "he has slept 9 hours each night for the past 2 years" c. "he is very religious and attends services twice a week" d. "he spends much of his time with his 2 school friends"

a. "his favorite teacher committed suicide a few weeks ago"

a nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. which of the ff responses should the nurse make? a. "it sounds like you're having a difficult time" b. "have you talked to your parents about this yet?" c. "why do you think you are so anxious?" d. "how long has this been going on?"

a. "it sounds like you're having a difficult time"

a nurse is providing teaching about confidentiality with a newly licensed nurse. which of the ff statements by the newly licensed nurse indicates an understanding of the teaching? a. "the court might require me to discuss confidential information" B. "i am required to provide confidential information to insurance companies" c. "if questioned during a police investigation, i am required to divulge confidential information" d. "i am legally allowed to discuss confidential information with the client's former therapist"

a. "the court might require me to discuss confidential information"

a nurse si caring for an adolescent client who has a new diagnosis of schizophrenia. the client's parents are tearful and express feelings of guilt. which of the ff statements should the nurse make? a. "you said that you feel guilty about your daughter's diagnosis. let's talk about what is causing you to feel this way" b. "you should not feel guilty about your daughter's diagnosis. schizophrenia is unpreventable" c. "i'm sure your daughter's diagnosis is very difficult to deal with, but everything will be alright once she receives the proper treatment" d. "your provider has explained the causes of schizophrenia. why do you feel guilty about your daughter's diagnosis?"

a. "you said that you feel guilty about your daughter's diagnosis. let's talk about what is causing you to feel this way"

a nurse is caring for a client who has dementia. when performing a mental status examination (mse) the nurse should include which of the ff data? (select all that apply) a. ability to perform calculations b. level of consciousness c. recall ability d. long-term memory e. level of orientation

a. ability to perform calculations c. recall ability d. long-term memory e. level of orientation

a nurse is performing an admission assessment for a client who has schizophrenia. which of the ff findings should the nurse identify as a negative symptom? a. affective flattening b. bizarre behavior c. illogicality d. somatic delusions

a. affective flattening

a nurse is caring for a client who has schizophrenia. the client states that he hears voices telling him to do "bad things". the nurse correctly identifies this finding as which of the ff? a. command hallucinations b. gustatory hallucinations c. cognitive distortion d. somatic delusion

a. command hallucinations

a nurse is performing a psychosocial assessment on an adolescent client. which of the ff should indicate to the nurse a potential risk for suicide? (select all that apply) a. death of a parent at a young age b. recent or impending move c. low parental expectations d. volunteering at a community center after school e. sudden decline in school performance

a. death of a parent at a young age b. recent or impending move c. low parental expectations e. sudden decline in school performance

a nurse in a mental health clinic is conducting a staff education session on schizophrenia. which of the ff manifestations should the nurse identify as negative symptoms? (select all that apply) a. delusions b. hallucinations c. anhedonia d. poor judgment e. blunt effect

a. delusions b. hallucinations c. anhedonia e. blunt effect

in order to integrate care of the mind and body, it is important for nurses to understand the ff. (select all that apply) a. how people react to illness and its effect b. provide holistic nursing c. assess the client for co morbid health conditions d. monitor the client for adverse effects of medications

a. how people react to illness and its effect b. provide holistic nursing

a nurse is caring for a client who has schizophrenia. which of the ff statements by the client indicates concrete thinking? a. i am aware the each problem has only one solution b. "i am a prophet of the most high king" c. the violence tell me that i must avoid large crowds d. i know that you and the other nurse are trying to poison me.

a. i am aware the each problem has only one solution b. "i am a p

a nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. which of the ff statements by the newly licensed nurse indicates understanding? a. i need to make sure that the potential victim is warned b. i need to keep the information confidential due to the client's right to privacy c. i can only discuss the client's threats with a court order d. i should verbally report this information to the psychiatrist

a. i need to make sure that the potential victim is warned

a nurse is caring for an adolescent who is experiencing indications of depression. which of the ff findings should the nurse expect? (select all that apply) a. irritability b. euphoria c. insomnia d. low self-esteem e. chronic pain

a. irritability c. insomnia d. low self-esteem

a nurse is communicating with a client who has just admitted for her treatment of substance use disorder. which of the ff communication techniques should the nurse identify as a barrier to therapeutic communication? a. offering advice b. reflecting c. listening attentively d. giving information

a. offering advice

the way we cope with a situation is strongly influenced by a. our appraisal of demands b. how we evaluate our options c. how we respond to problems d. none of the above

a. our appraisal of demands

coping can be characterized as (select all that apply) a. problem-focused coping b. emotion-focused coping c. meaning-based coping d. inability to cope

a. problem-focused coping b. emotion-focused coping c. meaning-based coping

in supporting patients through periods of illness and change it is helpful for the nurse to (select all that apply) a. review the patient's usual coping style b. identify realistic goals c. identify current priorities and establish meaningful and realistic goals d. tardive dyskinesia

a. review the patient's usual coping style b. identify realistic goals c. identify current priorities and establish meaningful and realistic goals

a nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. as the nurse approaches the client, he states, "i am at the end of my rope. i dont think i can take any more bad news." which of the ff responses should the nurse make? a. "most clients with anxiety issues benefit from lying down" b. "come with me to an area where we can talk without interruption" c. "providers usually recommend relaxation exercises for clients who are as upset as you are" d. "an antianxiety pill works best for situations like this"

b. "come with me to an area where we can talk without interruption"

a nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. which of the ff responses by the nurse is appropriate to give? a. "because you are a minor, i have to share any information that i feel is important with your parents" b. "i cannot promise that. i must share this information with other members of the team who are responsible for planning your care" c. "i will not violent our nurse-client relationship. the information we discuss will remain confidential between us" d. "i can see that you trust me, but you should share those feelings with your psychiatrist, not me"

b. "i cannot promise that. i must share this information with other members of the team who are responsible for planning your care"

a nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "yester noon the sun moon went over the rover to see the lawnmower." which of the ff manifestations is the client exhibiting? a. delusional disorder b. associative looseness c. hallucination d. anhedonia

b. associative looseness

a nurse is caring for a client who has schizophrenia. the client states "the government is forcing thoughts into my brain through satellites." the nurse should document that the client is experiencing which of the ff types of delusions? a. persecution b. control c. eromanic d. somatic

b. control

a nurse is caring for a client who smokes and has lung cancer. the client reports "im coughing because i have that cold that everyone has been getting." the nurse identify that the client is using which of the ff defense mechanism? a. reaction formation b. denial c. displacement d. sublimation

b. denial

a nurse is caring for a client who is experiencing a crisis related to anxiety. which of the ff actions should the nurse take? (select all that apply) a. avoid eye contact to prevent escalation of anxiety b. establish rapport with the client c. identify the cause of the anxiety d. validate the client's feeling e. develop a flexible crisis intervention plan.

b. establish rapport with the client c. identify the cause of the anxiety d. validate the client's feeling

a nurse decides to put client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. the nurse's actions are an example of which of the ff torts? a. invasion of privacy b. false imprisonment c. assault d. battery

b. false imprisonment

a nurse is caring for a client who has schizophrenia. which of the ff statements by the client indicates understanding of a relapse intervention plan? a. i can remember when my hallucinations first began b. i know which of my hallucinations trigger a relapse c. i record the number of hallucinations i have each day d. i will read as much information as i can about schizophrenia.

b. i know which of my hallucinations trigger a relapse

a nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. which of the ff actions should the nurse plan to take? a. place the client in seclusion if visual hallucinations are present b. limit the number of questions asked during assessments c. use frequent touch to provide client support d. directly tell the client that delusions are not real

b. limit the number of questions asked during assessments

a nurse hears a newly licensed nurse discussing a client's hallucination in the hallway with another nurse. which of the ff actions should the nurse take first? a. notify the nurse manager b. tell the nurse to stop discussing the behavior c. provide an in-service program about confidentiality d. complete an incident report.

b. tell the nurse to stop discussing the behavior

a nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. which of the ff actions should the nurse take? a. move the client to a private area so the conversation will not be disturbed b. use clarification to determine what the client is feeling c. speak to the client using an authoritative voice d. maintain constant eye contact with the client

b. use clarification to determine what the client is feeling

a nurse is talking with a client who is at risk for suicide ff the death of his spouse. which of the ff statements should the nurse make? a. "i feel very sorry for the loneliness you must be experiencing" b. "suicide is not the appropriate way to cope with loss" c. "losing someone close to you must be very upsetting" d. "i know how difficult it is to lose a love one"

c. "losing someone close to you must be very upsetting"

a nurse is caring for a client who has schizophrenia who consistently does the opposite of what the nurse asks of him. the nurse recognizes this as which of the ff alterations in behavior? a. automatic obedience b. waxy flexibility c. active negativism d. impaired impulse control

c. active negativism

a nurse is caring for a group of clients in an acute mental health facility. which of the ff clients has the legal right to refuse treatment? a. a 16 yr old client whose parents have requested treatment b. an adult client who has delusions and refuses treatment for religious reasons c. an older adult client who was voluntary admitted d. a client who is competent but was involuntary admitted

c. an older adult client who was voluntary admitted

a nurse is caring for a client who has schizophrenia and is experiencing a hallucination. which of the ff actions should the nurse take? a. act to the client as if the hallucination is real b. instruct the client to argue with the voices that are a part of the hallucination c. ask the client direct questions about the hallucinations d. tell the client that the hallucinations is not a part of reality.

c. ask the client direct questions about the hallucinations

a nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. which of the ff hallucinations is the priority for the nurse to address? a. visual hallucinations b. gustatory hallucinations c. command hallucinations d. tactile hallucinations

c. command hallucinations

a nurse is an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. which of the ff is the priority intervention for the nurse to make? a. promote appropriate behavior during group therapy sessions b. encourage client input in the treatment plan c. communicate with the client using concrete language d. demonstrate assertive behavior

c. communicate with the client using concrete language

a nurse is assessing a client who has schizophrenia. which of the ff behaviors should the nurse anticipate? a. periods of elation with unusual talkativeness b. preoccupied with folding clothes c. invents words that have no meaning d. recurrent thoughts of past trauma

c. invents words that have no meaning

a home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. the client is sitting on his front porch wit a shotgun in his arms. which of the ff actions should the nurse take? a. honk the horn to get the client's attention b. calmly speak the client's name out of the car window c. keep driving in a path that is going away from the client's house d. stop the car in the client's driveway and call the authorities.

c. keep driving in a path that is going away from the client's house

a nurse is planning care for a group of clients on a mental health unit. which of the ff actions should the nurse plan to take to create a therapeutic environment? a. plan to discuss any topic that is presented b. focus on client weaknesses to increase adaptation c. provide continuity of care by assigning the same staff d. allow the client to determine the boundaries of the nurse-client relationship

c. provide continuity of care by assigning the same staff

a nurse in a mental health facility is preparing to interview a client who has schizophrenia. which of the ff action should the nurse take? a. sit on the other side of the table from the client b. place the client in a chair higher than the nurse c. start the interview with a question the client can answer with a "yes" or "no" d. sit beside the client rather than facing him

c. start the interview with a question the client can answer with a "yes" or "no"

a nurse is caring for a client who has a mental illness. which of the ff actions by the nurse demonstrates ethical concept of autonomy? a. encouraging client feedback about satisfaction with the facility experience b. explaining unit rules and policies regarding unacceptable behaviors c. supporting the client's wish to refuse prescribed medications d. making sure the client understands expectations for client participation

c. supporting the client's wish to refuse prescribed medications

a nurse in an acute mental health unit is admitting a client who has a bipolar disorder. which of the ff findings supports the admitting diagnosis of acute mania? a. the client's spouse reports that client has recently gained weight b. the client is dressed in all black c. the client responds to questions with disorganized speech d. the client reports that voices are telling him to write a novel.

c. the client responds to questions with disorganized speech

a nurse is teaching a newly licensed nurse about reporting suspected child abuse. which of the ff statements indicates an understanding by the newly licensed nurse? a. "evidence must exist prior to reporting" b. "if the potential abuser commits to stopping the abuse, health care workers are not required to report it" c. i dont want to defame someone if the report is false" d. "if suspicion of abuse exists then reporting is mandatory"

d. "if suspicion of abuse exists then reporting is mandatory"

mind, body, and nursing can be describe using the ff terms a. dualism b. holism c. integration d. all of the above

d. all of the above

a nurse is conducting a group therapy meeting and is sharing a humorous story. when the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling, "you are all making fun of me." which of the ff behaviors is this client displaying? a. grandeur b. flight of ideas c. erotomania d. ideas of reference

d. ideas of reference

a charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. which of the ff aspects of communication should the nurse identify as component of verbal communication? a. personal space b. posture c. eye contact d. intonation

d. intonation

a nurse is discussing legal exceptions to client confidentiality with nursing staff. which of the ff statements by a staff member indicates an understanding of the teaching? a. the legal requirement for client confidentiality ceases if the client is deceased b. staff members are required to divulge information to attorneys if they call for information c. health care workers are not required to answer courts requests for information about a clients disclosure d. providers are required to warn if the client threatens harm

d. providers are required to warn if the client threatens harm

a nurse in an acute mental health facility is communicating with a client. the client states "i cant sleep. i stay up all night." the nurse responds "you are having a difficulty sleeping?" which of the ff therapeutic communication techniques is the nurse demonstrating? a. offering general leads b. summarizing c. focusing d. restating

d. restating

a nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. which of the ff actions should the nurse take first? a. establish a client relationship b. explain to the client that the behavior was unacceptable c. explore the truth of the client's statements d. set behavioral limits for the client

d. set behavioral limits for the client

a nurse is assessing a family as a system. which of the ff factors should the nurse include when assessing sociocultural context? a. the sense of self among individual family members b. the future goals of the family c. the roles of family members d. the family's religious practice

d. the family's religious practice

behaviors of BPD

mania: elevated mood, usually 1wk, usually requires hospitalization hypomania: less severe mania, no hospital, 4days rapid cycling: 4+ episodes of mania within 1 yr