Mental Health Exam IV

A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? a. Request a prescription for an antianxiety medication b. Provide the client with a stimulating activity prior to bedtime c. Dim the lights in the client's room at night d. Encourage the client to make decisions about her daily routine

A. Request a prescription for an antianxiety medication Administration of a PRN antianxiety med can decrease agitation and anxiety: SAFETY!

The most effective non-pharmacologic therapy for PTSD is CBT. Which form of non-pharmacologic psychotherapy contains elements of CBT and body-centered therapy? a. Exposure therapy b. Support therapy C. Eye-movement desensitization and reprocessing (EMDR) D. Acupuncture

C. Eye-movement desensitization and reprocessing (EMDR) EDMR is a form of psychotherapy that contains elements of several types of therapy, including CBT and body-centered therapy.

The nurse is offering education about sleep hygiene techniques to a client with post-traumatic stress disorder (PTSD. Which strategies should the nurse include in the teaching? Select All That Apply. a. "Exercise, but not within 3 hours of bedtime to help you feel more tired." b. "Sleep in for a few hours after you have a night of restless night sleep"' c. "Increase the temperature of the room." d. "Avoid the use of screens about 3 hours before sleep."

a. "Exercise, but not within 3 hours of bedtime to help you feel more tired." d. "Avoid the use of screens about 3 hours before sleep."

The nurse is caring for an adult client in the Emergency Department who has a dislocated shoulder and broken ribs after being physically abused by their spouse. The client states that they do not wish to leave the relationship. What is the most appropriate response by the nurse? a. "Let's work on developing a safety plan for repeated violence." b. "Here is a list of services that can help you." c. "Physical abuse in intimate partner relationships only worsens over time." d. "It must be very difficult to make the decision to leave an abusive relationship."

a. "Let's work on developing a safety plan for repeated violence."

The nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicate that the client is experiencing persecutory delusions? a. "The doctor is stealing my thoughts." b. "I can control everyone's thoughts through my own." c. "I feel bugs crawling on my skin." d. "Kim Kardashian is in love with me."

a. "The doctor is stealing my thoughts."

The nurse is caring for a client with early-stage Alzheimer's disease who has been newly prescribed donepezil (increases the availability of ACh). Which information should the nurse include in the teaching? Select All That Apply a. "You should try to avoid taking over the counter NSAIDS while on donepezil." b. "Nausea, diarrhea and vomiting are common symptoms." c. "This medication should help to reverse some of the memory loss you have experienced." d. "This medication works by reducing a chemical in the brain called glutamate that can be toxic." (this is describing memantine, not donepezil)

a. "You should try to avoid taking over the counter NSAIDS while on donepezil." b. "Nausea, diarrhea and vomiting are common symptoms."

Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing response? a. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. b. Clients diagnosed with schizoid personality disorder exhibit delusions and hallucinations, while clients diagnosed with avoidant personality disorder do not. c. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. d. Clients diagnosed with schizoid personality disorder have a history of psychosis, while clients diagnosed with avoidant personality disorder remain based in reality.

a. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone.

The nurse is caring for an older adult client with delirium who is experiencing restlessness. What are the most appropriate nursing interventions to include in the plan of care? Select All That Apply a. Close and frequent observation b. Administer PRN 0.5 mg lorazepam PO (benzos and diphenhydramine often cause delirium) c. Manage environmental stimulation d. Administer donepezil 10 mg PO (this is an Alzheimer's medication)

a. Close and frequent observation c. Manage environmental stimulation

The nurse has referred a client to the Hospital Elder Life Program (HELP). What interventions should the nurse expect to be implemented through this program? Select all that apply. a. Daily visits to encourage social interaction b. Medication adherence support c. Support with vision/hearing devices d. Therapeutic activities such as puzzles and coloring e. Assistance with feeding and drinking

a. Daily visits to encourage social interaction c. Support with vision/hearing devices d. Therapeutic activities such as puzzles and coloring e. Assistance with feeding and drinking

The nurse is caring for a client with early stage Alzheimer's dementia. What behavioral and psychological problems associated with dementia should the nurse assess for? Select All That Apply. a. Depression b. Hallucinations c. Anxiety d. Delusions (moderate stage) e. Wandering (moderate stage)

a. Depression c. Anxiety

A nurse is admitting a client who has been diagnosed w PTSD. Which of the following symptoms might the nurse expect to assess? SATA a. Feelings of guilt that precipitate social isolation b. Aggressive behavior that affects job performance c. Relationship problems d. High levels of anxiety e. Escalating symptoms lasting less than one month

a. Feelings of guilt that precipitate social isolation b. Aggressive behavior that affects job performance c. Relationship problems d. High levels of anxiety Rationale: Characteristic symptoms of PTSD include re-experiencing the traumatic event, a sustained high level of anxiety or arousal, general numbness of responsiveness, nightmares, inability to remember certain aspects of the traumatic event, depression, guilt feelings, substance abuse, anger, and aggressive behaviors. The full-symptom picture must present for more than one month and cause significant interference w social, occupational, and other areas of functioning.

The nurse is assessing an older adult client who has suddenly become confused and is showing disorganized thinking with incoherent speech. The nurse is concerned that the client may be experiencing delirium. What other features should the nurse assess for using the Confusion Assessment Method (CAM)? Select all that apply. a. Fluctuating course b. Poor memory c. Inattention d. Altered level of consciousness

a. Fluctuating course c. Inattention d. Altered level of consciousness

A family member asks the nurse about the client's chances of a positive outcome after being diagnosed with schizophrenia. Which of the following information should the nurse provide the family? SATA a. Good pre-morbid functioning can predict a positive outcome b. Early age of onset is often predictive of a positive outcome c. Males often tend to have more positive outcomes d. Negative symptoms are easier to manage and are indicators of a positive outcome

a. Good pre-morbid functioning can predict a positive outcome

A client who has been diagnosed with posttraumatic stress disorder asks the nurse what non-pharmacological treatments are available. Which treatments should the nurse include in the discussion? Select All That Apply a. Grounding exercises b. Exposure therapy c. Eye movement desensitization & reprocessing therapy d. Panic control treatment

a. Grounding exercises b. Exposure therapy c. Eye movement desensitization & reprocessing therapy

The nurse is caring for an older adult client with delirium secondary to hip replacement surgery. What findings should the nurse expect in this client? Select All That Apply. a. Hallucinations b. Unaltered level of consciousness c. Restlessness and agitation d. Slurred speech

a. Hallucinations c. Restlessness and agitation d. Slurred speech

The nurse has decided to perform the Alcohol Use Disorders Identification Test (AUDIT) screening test on a client. Which questions will the nurse be including as part of this assessment? SATA a. How often do you have a drink containing alcohol? b. Have people annoyed you by criticizing your drinking? c. How often do you have five or more drinks on one occasion? d. Have you ever had a drink first thing in the morning to steady your nerves?

a. How often do you have a drink containing alcohol? c. How often do you have five or more drinks on one occasion?

Which interventions are most appropriate for caring for a pt in alcohol withdrawal? SATA a. Monitor VS b. Provide a safe environment c. Address hallucinations therapeutically d. Provide stimulation in the environment e. Provide reality orientation as appropriate f. Maintain NPO status

a. Monitor VS b. Provide a safe environment c. Address hallucinations therapeutically e. Provide reality orientation as appropriate

The nurse is performing a brief interview as part of the SBIRT protocol. Which topics are most appropriate for the cover in the "provide feedback" part of this protocol? SATA a. Outline the client's risk category b. Explain guidelines and specific recommendations c. Use readiness for change ruler d. Connect drinking habits to client's specific medical problems

a. Outline the client's risk category b. Explain guidelines and specific recommendations d. Connect drinking habits to client's specific medical problems

The nurse has decided to perform the CAGE screening test on a client. What is the most likely rationale for choosing this assessment over the Alcohol Use Disorders Identification Test (AUDIT)? a. The CAGE captures higher risk behaviors and patterns than the AUDIT b. The CAGE assessment screens for alcohol withdrawal in chronic alcohol users c. The CAGE captures lower risk behaviors and patterns than the AUDIT d. The CAGE assessment screens for delirium tremens, a serious complication of alcohol withdrawal

a. The CAGE captures higher risk behaviors and patterns than the AUDIT

80-year-old Mr. Rogers, together with his daughter, arrived at the med-surg unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis? a. "Maybe it's just caused by aging. This usually happens at his age." b. "The changes in his behavior came on so quickly! I wasn't sure what was happening." c. "Dad just didn't seem to know what he was doing. He has been forgetful for years." d. "Dad has always been so independent. He's lived alone for years since mom died."

b. "The changes in his behavior came on so quickly! I wasn't sure what was happening."

The spouse of a pt admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? a. "Why don't you tell your spouse about this?" b. "What do you find difficult about this situation?" c. "This is not the best time to make that decision." d. "I agree with you. You should get out of this situation."

b. "What do you find difficult about this situation?"

The home health nurse visits a pt at home and determines that the pt is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? a. Ask the pt why they started taking illegal drugs b. Ask the pt about the amount of drug use and its effect c. Ask the pt how long they thought they could take drugs without someone finding out d. Do not ask any questions for fear that the pt is in denial and will throw the nurse out of the home

b. Ask the pt about the amount of drug use and its effect

The nurse is documenting the assessment for a client who has schizophrenia. Which of the following findings should the nurse document as a positive symptom of schizophrenia? a. Flat affect b. Auditory hallucination c. Avolition d. Alogia

b. Auditory hallucination

The nurse is caring for a pt diagnosed w paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? a. Increase socialization of the pt with peers b. Avoid using a whisper voice in front of the pt c. Begin to educate the pt about social supports in the community d. Have the pt signs a release of information to appropriate parties for assessment purposes

b. Avoid using a whisper voice in front of the pt

A client with a history of heavy alcohol use is brought to an emergency department by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician? a. Tactile hallucinations b. Blood pressure of 180/100 mmHg c. Mood rating of 2/10 on numeric scale d. Dehydration

b. Blood pressure of 180/100 mmHg The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated w alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

The nurse is caring for a client who has been diagnosed with posttraumatic stress disorder. Which findings would support this diagnosis? Select all that apply. a. Obsessive need to talk about the event b. Involuntary thoughts and recurrent nightmares c. The client feels detached and estranged from others d. The client is lethargic and somnolent

b. Involuntary thoughts and recurrent nightmares c. The client feels detached and estranged from others

Which of the following are true of Disulfiram? SATA a. It's an opioid antagonist b. It's an anti-alcoholic agent c. Opioid/Alcohol must be avoided in all forms d. If taken with opioids/alcohol, it will not cause harm e. Must be taken daily

b. It's an anti-alcoholic agent c. Opioid/Alcohol must be avoided in all forms e. Must be taken daily

A client with a history of alcohol use disorder exhibits tremor, nausea, headache, irritability, and mildly elevated heart rate (100 bpm). Which medication should the nurse anticipate administering to address these symptoms? a. Thiamine (B1) b. Lorazepam c. Naltrexone d. Disulfiram

b. Lorazepam Benzo for CNS depression to counter withdrawal

During a home visit, a client with a history of opioid use disorder is unresponsive, has pinpoint pupils, and has very shallow slow breathing. Which medication should the nurse prepare to administer? a. Naltrexone b. Naloxone c. Disulfiram d. Buprenorphine + Naloxone

b. Naloxone

Which of the following are seen in a pt during the moderate phase of Alzheimer's? SATA a. Anxiety b. Suspiciousness c. Wandering d. Incontinence e. Hallucinations f. Apathy

b. Suspiciousness c. Wandering e. Hallucinations

The nurse has received a client's white blood cell count result. Which client was most likely to have had this blood work ordered? a. The client who has been prescribed aripiprazole b. The client who has been prescribed clozapine c. The client who has been prescribed risperidone d. The client who has been prescribed benztropine

b. The client who has been prescribed clozapine

A pt diagnosed with delirium disoriented and confused at night. Which interventions should the nurse implement initially? a. Move the pt to the nurses' station b. Use an indirect light source and turn off the TV c. Keep the TV and a soft light on during the night d. Play soft music during the night, and maintain a well-lit room

b. Use an indirect light source and turn off the TV

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? a. Strongly encourage the client to attend 90 AA meetings in 90 days b. Educate the client about the medical consequences of chronic alcohol abuse c. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol d. Administer vitamin B1 to prevent Wernicke-Korksakoff syndrome

c. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol

The nurse is caring for a client who has paranoid delusions. What behaviors should the nurse expect to assess for this client? a. Pressured speech and extreme suspiciousness b. Psychomotor retardation c. Anger and aggression d. Echolalia and echopraxia

c. Anger and aggression

The nurse should recognize which medication as most effective in providing a client immediate relief from neuroleptic induced extrapyramidal side effects (EPS)? a. Lorazepam 1mg PO b. Haloperidol 5mg IM c. Benztropine 2mg PO d. Fluphenazine 2mg PO

c. Benztropine 2mg PO

The nurse is caring for a client with PTSD. Which symptoms should the nurse categorize as reflecting intrusive symptoms? SATA a. Irritability b. Easy startle reflex c. Flashbacks d. Nightmares

c. Flashbacks d. Nightmares

Which of the following is not true of Naltrexone? a. It will cause severe withdrawal if pt is dependent on opioids b. It can be effective for both alcohol and opioid dependence c. It can be used with opioid analgesics d. Causes reduced cravings and reduced rewards from drinking

c. It can be used with opioid analgesics

After being robbed and beaten by an unknown assailant, a patient is diagnosed w PTSD. When developing a plan of care for the patient, which of these interventions will the healthcare provider plan to implement first? a. Assist the patient in recalling the details of the event b. Teach the patient coping skills to deal with anxiety c. Promote the establishment of a trusting relationship d. Ensure the patient is taking medications as prescribed

c. Promote the establishment of a trusting relationship

A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome? a. Flat affect b. Refusal to accept help from others c. Report of intense guilt d. Denial of the sexual assault

c. Report of intense guilt Rationale: other findings of rape-trauma syndrome are mood swings/intense emotions, dependence on others

When teaching a client with alcohol use disorder about nutritional needs, which nutritional concepts should the nurse emphasize? a. Eat a high-protein, low carb diet b. Increase sodium risk foods c. Take a multivitamin that includes thiamine and folic acid d. Eat a diet high fiber diet

c. Take a multivitamin that includes thiamine and folic acid important for brain function

A client diagnosed with schizophrenia states, "Look, color, hate me, yes, bird, shoe." Which is an appropriate charting entry to describe this client's statement? a. "The client is verbalizing echolalia." b. "The client is verbalizing neologisms." c. "The client is verbalizing clang associations." d. "The client is verbalizing word salad."

d. "The client is verbalizing word salad."

The nurse is assessing a client who was physically assaulted 7 days ago. The client reports having nightmares, trouble focusing, and feeling as if they are walking around in a dream-like state. The nurse interprets these findings as most likely associated with which condition? a. Posttraumatic stress disorder b. Acute stress disorder c. Dissociative identity disorder d. Dissociative fugue

d. Dissociative fugue

A client who has been experiencing mild alcohol withdrawal becomes agitated and says, "I see bugs on the wall." What is the nurse's priority action? a. Administer lorazepam as ordered and maintain patient safety b. Reassure the client that this is normal symptom withdrawal c. Perform CIWA d. Get vital signs, assess for seizures, and contact the provider immediately

d. Get vital signs, assess for seizures, and contact the provider immediately This are signs of delirium tremens

The nurse is assessing a pt who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? a. Hypotension, ataxia, hunger b. Stupor, lethargy, muscular rigidity c. Hypotension, coarse hand tremors, lethargy d. HTN, changes in LOC, hallucinations

d. HTN, changes in LOC, hallucinations

A nurse is assessing a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal? a. Decreased appetite b. Slurred speech c. Insomnia d. Hallucinations

d. Hallucinations Other symptoms of severe alcohol withdrawal are diaphoresis, hyperthermia, and tachycardia. A decreased appetite and insomnia are a manifestation of mild/moderate alcohol withdrawal, slurred speech = alcohol intoxication

A nurse is assessing a client who is experiencing PTSD following a traumatic event. Which of the following medications should the nurse expect the provider to prescribe? a. Bupropion b. Phenelzine c. Mirtazapine d. Paroxetine

d. Paroxetine SSRIs are a first line defense for PTSD. Other meds commonly used are benzos, prazosin (for nightmares), and propranolol.

The nurse is caring for a client who has been diagnosed with PTSD-related nightmares. Which medication should the nurse expect to administer to this client? a. Paroxetine (SSRI appropriate for PTSD) b. Phenelzine (MAOI, so we do not used this for PTSD) c. Propranolol (blood pressure med used immediately after someone has experienced a traumatic event to prophylactically prevent PTSD) d. Prazosin (BP medication that reduces the intensity or frequency of the nightmares)

d. Prazosin (BP medication that reduces the intensity or frequency of the nightmares)