Mental Health Final

When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide?

"Have the feelings associated with these events brought you to the clinic?"

When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide?

"Have the feelings associated with these events brought you to the clinic?"

A 38-yea- old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her food to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate for the nurse to make?

"I'll leave your tray here. I am available if you need anything else."

A client tells the nurse that his father died after the client thought abut it for a few days. The nurse suspects the client is delusional and is demonstrating:

A magical thinking

A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. What is the most likely source of this client's current feelings of depression?

A sense of loss

A middle-aged remale client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse "I want to find out why these people are stalking me" which response should the nurse provide? A. "It sounds like this experience is frightening for you" B. "What makes you think people are stalking you?' C. "I know you are frightened, but no one is stalking you D. Do you think someone is trying to harm you

A. "It sounds like this experience is frightening for you"

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client include what priority problem? A. Acute confusion. D. Self-care deficit. is homeless and is exhibiting suspiciousness. The client's plan of care should abirb.com/hesi abirb.com/hesi B. Ineffective community coping C. Disturbed sensory percept

A. Acute confusion.

A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? A. Allow the client to rest and sleep. B. Ensure client attend groups addressing coping skills for dealing with depression. C. Begin planning for the clients discharge. D. Encourage verbalization of feelings.

A. Allow the client to rest and sleep.

The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother? A. Ask the mother if she has ever thought about harming herself or her child. B. Reassure the mother that her child will achieve some growth and development disabilities. C. Determine if the mother has other children who do not have developmental D. Encourage the mother to write thoughts and feelings in journal.

A. Ask the mother if she has ever thought about harming herself or her child.

A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg. B. Pulse rate of 68-78 BPM. C. Temperature of 99.5-99.7 F. abirb.com/hesi D. Respiration rate of 24 breaths per minute.

A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.

A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit? A. Ineffective sexual patterns. B. Impaired environmental interpretation. C. Disturbed sensory perception. D. Compromised family coping.

A. Ineffective sexual patterns.

A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the clients plans of care? A. Initiate caloric and nutritional therapy. B. Implement behavioral modification therapy. C. Evaluate the client for low self-esteem. D. Record daily weights and graft trend.

A. Initiate caloric and nutritional therapy.

A young adult male is hospitallizaed due to depression and an attempted suicide attempt. The client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving? A. Initiates interactions with other clients. B. Describes verbally when he is angry C. Participates in a job search with a social worker. D. Denies plans to harm himself or others.

A. Initiates interactions with other clients.

A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? A. Not sleeping for several days. B. Wishing to be with spouse. C. Lack of interest in usual activities. D. Eating very little.

A. Not sleeping for several days.

A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take? A. Offer to play a game of cards with the client. B. Report the behavior to the next shift. C. Document the behavior in the chart. D. Plan to talk with the client the next day.

A. Offer to play a game of cards with the client.

Aclientwhoisadmittedwithaclosedheadinjuryafteragallhasabloodalcohol abirb.com/hesi level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority? A. Place in a side-lying position with head of bed elevated. B. Administer disulfram (Atabuse ) immediately C. Give lorezapam (Ativan)PRN for signs of withdrawal. D. Provide thiamine and folate supplements as prescribed.

A. Place in a side-lying position with head of bed elevated. (Maintain patient's airwat is the priority for a client who is intoxicated and obtunded)

After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. What action should the nurse take? A. Recommend assignment to the receptionist's office. B. Suggest that the student work in the athletic department. C. Refer the student to a psychiatrist for further discussion. D. Determine the parent's opinion of the work assignment

A. Recommend assignment to the receptionist's office.

A female client admitted to the mental health unit starts to shout and scream at he RN. What is the best approach for the RN to take? A. Stay quietly with the patient B. Tell her that she is out of control. C. Distract her by offering her finger foods. D. Ignore the client's acting out behavior.

A. Stay quietly with the patient

While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The nurse' ability to directly observe the client's nonverbal communication is limited with note taking. B. Taking notes during an interview is a legal obligation of the examining nurse. C. The client's comfort level is increased when the nurse breaks eye contact to take note to take note. D. The interview process is enhanced with note taking and allows the client speak at normal pace.

A. The nurse' ability to directly observe the client's nonverbal communication is limited with note taking.

Anorexia Nervosa-syncope Syncope is a clinical feature

Abuse-BAL-

41.A client comes into the ED with DTs. What should the nurse do first?

Administer Ativan.

A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response?

Advise the client that nursing assignments are not based on client requests.

When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide?

All clients are screened for domestic abuse because it is common in our society

60.When opening a mental health clinic...

American Nursing Association.

The nurse determines the client's blood alcohol level(BAL) was not analyzed on administration action should the nurse take

Ask client about alcohol quantity, frequency, and time of last drink

A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take?

Ask client about alcohol quantity, frequency, and time of last drink.

Client sitting in corner of day room during admission assessment, what nursing action

Ask client simple questions

A male client admitted depression and self-mutilation

Ask if the client has a plan to harm himself

A nurse observes a client in the dayroom talking to himself. What should the nurse do first?

Ask the client if he's currently hearing voices?

A male client who is seen in the mental health clinic monthly reports feeling very stressed and nervous and further describes becoming angry increasingly more often during the last month. What action should the nurse take first?

Ask the client to identify problems that have occurred during the last month

When performing a MSE on a client which assessment intervention would best assist the nurse?

Ask the client to interpret the proverb a stitch in time saves nine.

A client comes out dressed in short skirt, low top, bright red lipstick.. what should the nurse do

Assist the client back to their room and help pick out appropriate clothing

After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first?

Assist the client out of bed and involve in activity.

A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention?

Attempt to distract the client with general conversation.

a client is being discharged with a prescription of paroxetine. which in traction is most important for the nurse to include in this client's discharge?Avoid alcohol

Avoid alcohol

A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide? A. "Let's go ask another RN is this is true." B. "My name tag shows that I am a RN here." C. "I can't possibly be one if your children." D. "I know that you don't have 20 children."

B. "My name tag shows that I am a RN here."

A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client's current feelings of depression? A. Feelings of frustration. B. A sense of loss C. Poor self-esteem. D. A lack of intimate relationships.

B. A sense of loss

While setting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrate the client's behavior. What is the main goal of this therapeutic techniques? A. Discuss the client's feeling when he responds. B. Allow the client to identify the way he interacts C. Initiate a non-threatening conversation with the client. D. Dialog about the ineffectiveness of his interactions.

B. Allow the client to identify the way he interacts

A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority? A. Identify support systems in the community that may be helpful. B. Help the client feel safe to decrease anxiety. C. Ask the client to describe coping strategies that were helpful in the past. D. Encourage the client to verbalize anxiety related to event.

B. Help the client feel safe to decrease anxiety.

Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? A. At least I hit the wall instead of hitting the psychiatric aide. B. I am here because the police thought I was doing something wrong. C. I want to be here because I know it is the best psychiatric facility. D. Don't believe everything my family tells you, I am not crazy.

B. I am here because the police thought I was doing something wrong.

A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable? A. Encourage oral fluids. B. Monitor vital signs. C. Keep the room dark. D. Apply ice to his tongue.

B. Monitor vital signs.B. Monitor vital signs.

A male who was found sitting in the middle of a busy street is brought to the emergency department. Confused and has difficulty answering questions. After ruling out a physiological etiology for the client's behavior. When admitting the client to the unit, which action is most important for the nurse to take? A. Ask the client about his recent substance use B. Perform a mental status exam C. Determine the number of previous hospitalizations D. Assess the client from head-to-toe

B. Perform a mental status exam

The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing? A. Provide detailed thorough explanations when cleansing wound. B. Perform the dressing change in a non-judgmental manner. C. Ask in a non-threatening manner why the client cut own abdomen. D. Request another staff member assist with the dressing change.

B. Perform the dressing change in a non-judgmental manner.

The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation? A. A summary of the client's feeling B. Photographs. C. A general description. D. A client's significant other's statement.

B. Photographs.

The nurse is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare providers A. Body mass index of 21 B. Potassium level of 2.9 mEq/dl C. WBC of 10,000 mm3 D. Blood pressure of 110/70 mmHg.

B. Potassium level of 2.9 mEq/dl

A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from...inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care? A. Relax and reduce the amount of effort to solve theproblem B. Recall methods that were most successful in the past C. reach out to family and friends about feelings of abandonment D.turntootheractivitiestotakeone'smindoffoftheissues

B. Recall methods that were most successful in the past

Anantidepressantmedicationisprescribedforaclientwhoreportssleepingonly4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? A. Meet scheduled appointment with dietitian. B. Sleep at least 6 hours a night. C. Understands the purpose of the medication regimen. D. Describes the reasons for hospitalization.

B. Sleep at least 6 hours a night.

A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A. Transport of the client to the seclusion room. B. Take other clients in the area to the client lounge. C. Quietly approach the client with additional staff members. D. Administer medication to chemically restrain the client.

B. Take other clients in the area to the client lounge.

A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A. Provide education on methods to enhance sleep. B. Teach the client to develop a plan for daily structured activities. C. Suggest that the client develop a list of pleasurable activities. D. Encourage the client to exercise.

B. Teach the client to develop a plan for daily structured activities.

An adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. His appetite. B. The emotional quality of his attitude C. His level of activity. D. The interactions he has with others.

B. The emotional quality of his attitude

A male college student visits the student health center for his annual physical examination. His vital signs and blood glucose...range. His height is 6 feet and 1 inch (185.4 cm), and he weighs 135 pounds (61.36kg). What additional information is most...obtain? A. 24-hour nutritional history B. body mass index C. basalmetabolicrate D. completebloodcount

B. body mass index

A young male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating...he tells the school nurse that wants to live away from home for college. What information is most important for...family? A. Despite his illness, the client should be able to live away from home B. his serum lithium levels should be routinely evaluated C. he should plan to participate in group or individual therapy while at college D.he should be aware of the symptoms of his illness

B. his serum lithium levels should be routinely evaluated

The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT? A. Hold all bedtime medications. B.Keep the client NPO after midnight C. Implement elopement precautions. D. Give the client an enema at bedtime

B.Keep the client NPO after midnight

A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death?

Becomes the faculty sponsor for students against drunk driving (SADD)

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body confort into a monster. What action should the nurse take? A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril) abirb.com/hesi B. Offer the client a prescribed physical therapy hot pack for muscle spasms. abirb.com/hesi C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. D. Direct client to occupational therapy to distract him from somactic complaints.

C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique? A. Initiate a non-threatening conversation with the client. B. Dialog about the ineffectiveness of his interactions. C. Allow the client to identify the way he interacts. D. Discuss the client's feelings when he responds.

C. Allow the client to identify the way he interacts

The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?A. Don't allow the client to go into the kitchen until the hallucination has subsided. B. Report the behavior to the client's case workers so that the family can be notified. C. Assign the UAP to remain with the client at all times. D. Document the behavior in the client's record and notify the HCP.

C. Assign the UAP to remain with the client at all times.

The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement? A. Monitor the client's appetite and pattern of sleep. B. Assess the client's feelings about the hospital stay .C. Assist the client to get out of bed and involved in an activity. D. Explain that staff will check on the client every 30 minutes.

C. Assist the client to get out of bed and involved in an activity.

The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement? A. Monitor the client's appetite and pattern of sleep. B. Assess the client's feelings about the hospital stay. C. Assist the client to get out of bed and involved in an activity. D. Explain that staff will check on the client every 30 minutes.

C. Assist the client to get out of bed and involved in an activity.

An adolescent male client is hospitalized after he threatened a teacher at school. He admits feeling angry because his mother tricked him and brought him to the hospital. The client states that when his mother visits, he plans to get his belongings from her, but he is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives? A. Assess the client's self-esteem needs. B. Determine the client's expectations for treatment. C. Discuss methods for clearly communicating. D. Identify ways to develop support systems.

C. Discuss methods for clearly communicating.

Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where the group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address? A. Medication non-compliance. B. Number of bathroom facilities C. Infection control D. Acting out behaviors

C. Infection control

A male client with along history of alcohol dependency arrives in the Emergency department describing the feeling of bugs crawling on his body. His blood pressure is 170/102, pulse rate is 110 beats/ min, and his blood alcohol level is 0 mg/dl. Which prescription should the nurse administer? A. Haloperidol (Hadol) B. Thiamine (Vitamin B1) C. Lorazapam (Ativan) D. Diphenhydramine (Benadryl)

C. Lorazapam (Ativan)

A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? A. Discuss checking the time frequently B. Ask the client why she checks the locks C. Plan a list of activities to be carried out daily D. Determine the type and sizes of the locks

C. Plan a list of activities to be carried out daily

A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? A. Dim the lights in the room to help the patient feel calm. B. Sit within two feet of the client to enhance level of safety and security. C. Reduce the noise level in the room by turning off the television and radio. D. Position table between the client and the RN for extra personal space.

C. Reduce the noise level in the room by turning off the television and radio

The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting? A. Opportunities to contribute to one's treatment plan. B. One on one dialogue sessions with the therapist. C. Regularly scheduled unit activities for peer interaction D. Home visits to reintergrate into family

C. Regularly scheduled unit activities for peer interaction

The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting? A. Opportunities to contribute to one's treatment plan. B. One on one dialogue sessions with the therapist. C. Regularly scheduled unit activities for peer interaction. D. Home visits to reintergrate into the family.

C. Regularly scheduled unit activities for peer interaction.

A male veteran who recently returned from a war zone has post traumatic stress disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicidal ideation. On admission, the client's family informed the HCP that therapy sessions did not seem to be helping. Select only one intervention that as the highest priority? A. Administer paraxeitne 40 mg as prescribed. B. Develop a list of therapy programs. C. Remove all shaving equipment. D. Determine if client has a suicide plan.

C. Remove all shaving equipment.

An older man with a hx of falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become abusive since his release from prison. Which intervention is most important for the nurse to implement? A. Tell the client to call Adult Protective Services if his son's abuse continues. B. Refer the client to a program for victims of domestic violence C. Verify the client's report by determining if there is physical evidence of abuse D. Assist the client in developing an emergency safety plan

C. Verify the client's report by determining if there is physical evidence of abuse

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping. Which action should the nurse take? A.instructtheclienttoreducethevolumeofhisvoice B. administer a PRN sedative by injection C. accompany the client to a quiet area of the unit D.encouragetheclienttoattendasupportgroup

C. accompany the client to a quiet area of the unit

What should you advise a patient a MAOI not to eat?

Cheese, beer, and avocadao

A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism?

Compulsion

A mother comes into the clinic with her son who is being accused of a crime. She is worried her son will go to jail. What should the nurse say to the mother?

Consequences of enabling behaviors.

A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement?

Consult with the healthcare provider about reducing the dosage

32.A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality what would the nurse do?

Contact the person the client chooses to go to the home and remove the weapon.

Conversion disorder patient complains of blindness Which question is most important to include in this assessment?

Conversion Disorder characterized by transferring a mental conflict into a physical symptom for which there is no organic cause. Ex: blindness, paralysis, seizures, deafness, and pseudocysts (false pregnancy).

Schizoprenia return to clinic 2 weeks after recieving dose of haldol; important info for the nurse to obtain during this visit

Current vital signs

The occupational health nurse is working with a female employee who was notified that her child was involved in a MVA and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the RN to provide in this crisis? abirb.com/hesi A. Tell me what you think should happen. B. How serious was the collision? C. What do you think you should do? D. Call for transportation to the hospital.

D. Call for transportation to the hospital.

A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client's husband recently lost his job she feels her employment is essential to the family's survival. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care? A. Relates insight into problematic relationships abirb.com/hesi B. Demonstrates a healthy relationship with husband. C. Described how the family can resolve problem. D. Changes thought patterns related to problem solving

D. Changes thought patterns related to problem solving

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first? A. Refer the client to the cardiology unit. B. Obtain the client Blood pressure. C. Assess the client for substance abuse. D. Determine if Xanax was taken recently.

D. Determine if Xanax was taken recently.

The nurse is using the CAGE questionnaires as screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool? A. Consumption, liver enzyme, gastrointestinal complains and bleeding. abirb.com/hesi B. Minimizes drinking frequently misses family events, guilt about drinking, and amount of daily intake. C. Cancer screening results, anger, gastritis, daily alcohol intake. abirb.com/hesi abirb.com/hesi D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener"

D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener" (the acronym of CAGE)

A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. That intervention is best for the nurse to implement? A. avoid recognizing the behavior. B. Isolate the client from other clients. C. Administer a PRN sedative. D. Escort the client to his room.

D. Escort the client to his room.

10.The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A. Establishing a rapport with group members. B. Clarifying the nurse's role and clients' responsibilities. C. Discussing ways to use new coping skills learned. D. Helping clients identify areas of problem in their lives.

D. Helping clients identify areas of problem in their lives.

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. What action should the nurse implement first? A. Administer a PRN sedative. B. Sit in the chair next to the client. C. Escort the client to his room. D. Listen to what the client is saying.

D. Listen to what the client is saying.

The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? A. Short term memory loss. B. Five pound weight gain C. Decreased affect. D. Nausea and vomiting.

D. Nausea and vomiting.

A female client, who is wearing dirty clothes and has afoul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take? A. Assure client that the healthcare provider will see her today. B. Recommend that the client talk with a social worker. C. Ask the client to describe why she is being stalked. D. Offer the client a safe place to relax before interviewing

D. Offer the client a safe place to relax before interviewing

A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement? A. Assure the client that all food served in the hospital is safe to eat. B. Tell the client that irrational thinking is a symptom of schizophrenia. C. Obtain an order for a tube feeding for the client. D. Provide the client with food in unopened containers.

D. Provide the client with food in unopened containers.

A middle-aged adult with major depressive disorder suffer from psychomotor redardation, hypersomnia, and amotivation. Which intervention is like to be most effective in returning this client to a normal level of functioning? A. Encourage the client to exercise. B. Suggest that the client devaebloirpba.cloismt o/fhpelesai surable activities. C. Provide education on methods to enhance sleep. D. Teach the client to develop a plan for daily structured activities.

D. Teach the client to develop a plan for daily structured activities.

What is the most important goal for a client with major depression who has been receiving an antidepressant medication for two weeks? A. ventilate feelings of sadness B. eats three meals a day C. participates in group meetings D. does not attempt to commit suicide

D. does not attempt to commit suicide

50. A female client with obsessive compulsive disorder complains that she is feels "driven" to check the locks on her front door at.. Which response is best for the nurse toprovide? A. have you had a bad experience related to unlocked doors? B. What are your thoughts when you are checking the locks? C. feelings of being drive to do something are related to anxiety D. repeating the same behavior helps you to diminish your anxiety

D. repeating the same behavior helps you to diminish your anxiety

A client with an anxiety disorder is demonstrating signs of panic. Which intervention would be the most appropriate for the nurse to implement

Decrease environmental stimuli and interactions with other people.

What are the side effects of Lithium?

Dehydration, diarrhea, and thirstiness.

A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia?

Delirium: Started in hospital.

A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates to his room and sometimes opens the door to peek into the hall. Which problem can the nurse anticipate?

Delusions of persecution

The nurse overhears a client diagnosed with terminal cancer tell a family member that he will be discharged soon, will return to work, and plans to attend a company abirb.com/hesi event scheduled in a year. The nurse realizes this client is demonstrating the defense mechanism of

Denial

The nurse is assessing a client with postpartum depression for changes in the .......Sign & Symptoms that are consistent with postpartum depression? Select all that apply

Disturbed sleep Sadness Poor concentration

What are the signs of postpartum depression (Select all that apply)

Disturbed sleep Sadness Poor concentration

A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx?

Disturbed thought process.

The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment?

Do you frequently have tantrums?

A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first?

Do you have a plan in place when you are not safe? (SAFETY!!!)

Common side effects of antidepressants?

Dry mouth Constipation Blurred vision

Antisocial- interrupting A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement?

Escort the client to a quieter place.

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first? Explain the nurse's role to the client

Explain the nurse's role to the client

A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship:

Explore the client's feelings related to discharge

A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship?

Explore the client's feelings related to discharge

36.Who is most prone to being abused (elder abuse)?

Females over 75 living with their families.

42.What are the side effects of Resperdal?

Fever, tachycardia, and sweating.

6. male employee says I'm going to shoot a coworker

Find out if he has a weapon

A man comes into the ER after being in a car accident with an alcohol level greater than 2, what should the nurse prepare to administer?

Give Ativan

A client taking Meth and Benzo's, what would the nurse prepare to do for overdose?

Give Naloxone (Narcan)

A client in the dayroom had tipped over a table and is escalating and has picked up a chair which he is threatening to throw at another client. What should the nurse do first?

Go and get more staff assistance.

A client tells the nurse that he is an accomplished writer and that directors of television shows contact him for suggestions on actors and locations. The nurse realizes this client is experiencing the delusion of

Grandiosity

What is a common side effect of cocaine use?

Heart attack.

The nurse has identified the diagnosis imbalance Nutrition: More than body requirements for a client diagnosed with bulimia. Which intervention would be appropriate for this diagnosis?

Help client assess situations that precedes binging

A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)?

How would you like to be involved with your husband's care?

A female client diagnosed with depression tells the nurse that her husband wants her to "fix herself up" and put on nice clothes. The client continues by saying that she believes her husband is interested in another woman. What should the nurse respond to the client?

I can help you shower and get dressed before he comes to visit

depressed mother and daughter speaks in group

I hear you say you worry about your mother's distress

A man who was stranded on the roof of his house for two days after a natural disaster, months later

Implement anxiety control strategies

Patient who had generalized anxiety disorder is on Alprazolam for a long-term. What is the outcome?

Importance of not quickly stopping the drug

During an assessment, a client from the Hispanic culture refuses to maintain eye contact with the nurse. After the nurse overhears the client say "evil eye" to a family member, the nurse realizes the client is demonstrating characteristics of which cultural-specific syndrome?

Induced by witchcraft

A client with a hx of depression and abusing alcohol with their depression getting worse. What is the most important nursing dx?

Ineffective coping

A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels

Infection control.

A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels.

Infection control.

A bipolar client comes into the clinic and tells the nurse that the next time she sees her sister I'm going to kill her. What should the nurse do?

Inform the sister

A client tells the nurse that he has a fear of flying on an airplane but needs to attend a work-related meeting in another part of the country and will have to fly to get there. What can the nurse do to assist this client?

Instruct the client to visualize flying to the meeting destination

The nurse is taking the history of a young adult female who is 5 feet 4 inches tall and weighs. What is the most important for the nurse to address immediately?

Intermittent palpitations

Assessing male client with paranoia, which behavior can this client be expected to exhibit

Is openly hostile towards others for no apparent reason

Alzheimer's patient-nurse goes to do dressing change and the client refuses. What should the nurse do?

Leave and come back 30 minutes later.

A business man is stressed about his finances, has anxiety and sleeplessness.

Limit intake of sugar and caffeine.

A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assessment findings with the healthcare provider, a serum creatinine is obtained. What information supports the reason for this laboratory test?

Lithium is excreted by the kidneys and creatinine is related to kidney functioning

A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take?

Lorazepam (Ativan) 8 mg PO HS

A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take?

Lorazepam (Ativan) 8 mg PO HS

A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first?

Magnesium

A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust?

Make brief contact with the client throughout the day.

Chronically depressed older male client of a long-term care facility becomes more reclusive and today refuses to leave room

May I sit with for you a while

Teen in ER for threatening teacher. what interventions should the nurse implement?

Methods of clearly communicating

2 days after admission from alcohol withdrawal what should the nurse do?

Monitor HR and BP

A patient has stopped taking sodium valproate Depakote six months ago, what would the nurse assess?

Mood.

A client comes to the nurses' staatibonirba.ncdotmold/htehesinurse that her roommate had cut her wrists in the bathroom. After assessing and dressing the wounds, what should the nurse do next?

Move the client to a private room by the nurse's station.

ECT

NPO after midnight

A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first

Observe the client in the chair

9. A client with a history of chronic alcohol abuse... what other medical condition to suspect

Pancreatitis

40.What is the most important intervention for a client with bulimia?

Plan scheduled meals. abirb.com/hesi

A client who is admitted to the substance abuse center reports having nightmares -

Provide a dark, quiet, and comfortable atmosphere.

PTSD admitted to psychiatric unit, which intervention is most important for plan of care

Provide a quiet rook, away from the recreational area

In adolescent group discussing a handout on anger management, a client is becoming increasingly interruptive and talking about his home and pets. What is the nurse's most appropriate response?

Redirect the client to read the handout.

A client diagnosed with schizophrenia has been refusing prescribed oral medication for several days. The client has broken chair and is coming after another client with the broken chair leg, threatening to do physical harm. What should the nurse do first?

Remove the other client from the room.

A client in group is talking about prostitution, the nurse asks if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used?

Repression

An alcoholic father tells his wife and children to stay away from him. What is the most important nursing dx?

Risk for injury.

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent.............

Silence is reflecting the client'ssadness

A client comes in and is 5'5, 75lbs.. what should the nurse do

Start an IV for IV resuscitation

Patient says, "I'm going to shoot myself"

Stop the client from leaving the unit

A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanisms is being used?

Sublimation

An elderly woman is brought to the ER with multiple stages of healing bruises. What should the nurse do?

Take the woman aside and ask her about abuse.

A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3 days. What should the nurse do?

Take to quiet room and give PB crackers.

A client on LSD comes into the ER. How do you approach the client?

Talk calmly and soothing to the client.

The patient states "I can't get my thoughts together I should really sell my car. It's not in here. Let's buy a car. What is the patient experiencing?

Tangential thinking

one on one session and nurse begins to get angry at patient

Terminate session

What would be the nurse's highest priority for a newly admitted depressed client upon admission?

The nurse should go through the client's belongings.

A child states "My dad used to drink a beer a day, now he drinks at least a six-pack a day." What can the nurse determine from this statement?

The parent is exhibiting tolerance to alcohol

A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery?

Thiamine will replenish alcohol effects on the body (something to do with iron)

A client with dementia uses the defense mechanism of confabulation. What is the reasoning?

To decrease anxiety

History of alcoholism admitted for detoxification; 6mg of Ativan what additional prescription administer immediately

Vitamin B1 (thiamine)

A client who is refusing to take his medication is wandering on the unit and going in and out of resident's rooms. What is the priority?

Wandering in and out of other client's rooms.

The parents of a teenager who has overdosed what is the first question to ask?

What drug did the client ingest?

Older man who recently got divorced and is 2years sober, and an alcoholic lovesGod.He loves kids also. What should nurse ask at his initial interaction?

What is troubling you most.

A client is told to come in by friends, client's complaints include losing his job, just got a divorce, single dad with two kids, what would be the best question for nurse to ask?

What is troubling you the most?

A sales executive presents to the psychiatric office for an initial evaluation and tells the nurse "My therapist said my wife was having an affair. I had drinking problem for years, but I have been sober for 3 years. I believe in God....... What response is best for the nurse to provide?A sales executive presents to the psychiatric office for an initial evaluation and tells the nurse "My therapist said my wife was having an affair. I had drinking problem for years, but I have been sober for 3 years. I believe in God....... What response is best for the nurse to provide?

What is troubling you the most?

A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response?

When you interrupt, I cannot explain what to do to the group.

A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response?

You didn't do anything wrong. You have a chemical imbalance in your brain.

A client with Alzheimer's keeps asking for his mother. What is the nurse's appropriate response?

Your mothers not here but you are safe.

A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? a. Allow the client to rest and sleep. b. Ensure client attend groups addressing coping skills for dealing with depression. c. Begin planning for the clients discharge. d. Encourage verbalization of feelings.

a. Allow the client to rest and sleep.

During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? a. Assist the client in developing alternative coping skills. b. Remain calm and use a matter of fact approach. c. Ask the client why she is so anxious d. Administer a PRN sedative to help relieve her anxiety.

a. Assist the client in developing alternative coping skills.

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states" I don't need to be here," and tells the RN that she believes that the T.V. talks to her. The RN should document these assessment statements in which section of the mental status exam? a. Insight and judgement. b. Mood and affect. c. Remote memory. d. Level of concentration.

a. Insight and judgement.

A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine? a. Weight gain of 75 lbs. b. Thoughts of wanting to hurt himself. c. Frequent days with diarrhea. d.Alerted liver function test.

a. Weight gain of 75 lbs.

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? a.Is attempting to physically restrain the patient. b.Tells the client to go to the quiet area of the unit. c.Is using a loud voice to talk to the client. d.Remains at a distance of 4 feet from the client.

a.Is attempting to physically restrain the patient

A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? a.Report the client's serum lithium level to the HCP. b.Encourage the client to suck on hard candy to relieve the symptoms. c.No action is needed since polydipsia is a common side effect. d.Tell the client that drinking from the faucet is not allowed.

a.Report the client's serum lithium level to the HCP

patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contact healthcare provider before giving

acetaminophen

client sitting in corner of day room during admission assessment, what nursing action

ask client simple questions

The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? a. Lithium. (Lithotabs) b. Benzotropine (Cogentin). c. Alprazolam (Xanax). d. Magnesium (Milk of Magnesia).

b. Benzotropine (Cogentin).

The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA) a. Purchase a gun to use for protection. b. Establish a code with family and friends to signify violence. c. Take a self-defense course that retaliates the abuser with injury d. Have a bag ready that has extra clothes for self and children. e. Plan an escape route to use if the abuser blocks the main exit.

b. Establish a code with family and friends to signify d. Have a bag ready that has extra clothes for self and children. e. Plan an escape route to use if the abuser blocks the main exit.

A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client? a. When was the last time you drank alcoholic beverage? b. Have you taken any medications for erectile dysfunction? c. Are you having any other sexual dysfunctions or problems? d. Do you have a history of angina or high blood pressure?

b. Have you taken any medications for erectile dysfunction?

Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? a. At least I hit the wall instead of hitting the psychiatric aide. b. I am here because the police thought I was doing something wrong. c. I want to be here because I know it is the best psychiatric facility. d.Don't believe everything my family tells you, I am not crazy.

b. I am here because the police thought I was doing something wrong.

A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? A. Pan- seared catfish B. Peperoni pizza C. Deep fried shrimp D. Beef trips with gravy.

b. Peperoni pizza

A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding? a. Admit to others that he is a substance abuser. b. Remain alcohol free for 12 hours prior to first dose. c. Attend monthly meetings of alcoholics anonymous. d. Completely sustain from heroin or cocaine use.

b. Remain alcohol free for 12 hours prior to first dose.

A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations? a. Deficient diversional activity related to excess energy level. b. Risk for other related violence related to disruptive behavior. c. Risk for activity intolerance related to hyperactivity. d. Disturbed personal identity related to grandiosity.

b. Risk for other related violence related to disruptive behavior.

6. A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response is best for the nurse to provide this client? a.) "I am not the best nurse. All the nurses are good." b.) "The other nurses and I are here to help you get better" c.) "You don't think the other nurses care about you?" d.) "I do care about you as a person but nothing more."

b.) "The other nurses and I are here to help you get better"

An older ale client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? a. Explain that the feces belong in the toilet. b. Show the client how to clean the walls. c. Escort the client out of the bathroom. d. Assist the client to clean the walls

c. Escort the client out of the bathroom.

A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? a. Dim the lights in the room to help the patient feel calm. b. Sit within two feet of the client to enhance level of safety and security. c. Reduce the noise level in the room by turning off the television and radio. d. Position table between the client and the RN for extra personal space.

c. Reduce the noise level in the room by turning off the television and radio.

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? a. Impaired comfort. b. Risk for injury. c.Ineffective breathing pattern. d.Ineffective coping.

c.Ineffective breathing pattern.

The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Useof which substance places the client at highest risk for myocardial infarction? a. Benzodiazepine b.Alcohol c.Methamphetamine d.Marijuana

c.Methamphetamine

A26-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells her the nurse, "please let me leave because the secret police are after me."Which response is best for the nurse

come with me to your room and I will sit with you

A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? a. Unless your sister has a medical education, ignore her comments. b. I can hear that your sister's comments are overwhelmingyou. c.Do you think it's possible that you might be ahypochondriac? d. Besides your sister's comments, what in your life is troubling you?

d. Besides your sister's comments, what in your life is troubling you?

Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins toexhibit signs and symptoms of delirium tremens (DTs)? a. Prochlorperazine (Compazine) 5 mg IM. b. Hydromorphone (Dialuadid) 2 mg IM. c. Chlorpromazine (Thorazine) 50 mg IM. d. Lorazepam (Ativan) 2 mg IM.

d. Lorazepam (Ativan) 2 mg IM.

The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? a. Short term memory loss. b. Five pound weight gain c. Decreased affect. d. Nausea and vomiting.

d. Nausea and vomiting.

A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client's chief complaint in the medical record? a.) Client reported that she had sexual relations against her will. b.) Client claims that she was forced to participate in sexual intercourse. c.) Client has been sexually assaulted. d.) Client states, "my date raped me tonight."

d.) Client states, "my date raped me tonight."

A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement? a."What should I do? Nothing seems to help." b."I have been so tired lately and needed to sleep." c."I really think that I don't need to be here." d."I don't want to walk. Nothing matters anymore."

d.I don't want to walk. Nothing matters anymore."

postpartum depression Sign & Symptoms (3)

disturbed sleep, sadness, poor concentration

A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

do not take any over the counter meds

antidepressant side effects

dry mouth, blurred vision, constipation

stealing clothes

encourage client to actively participate in activity

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

establish trust by providing a calm, safe environment

Teenaged girl self-induced vomiting

frequency of binging and purging behaviors

ECT therapy non responsive

have you taken erectile dysfunction meds

no TV in room tell patient

it is important to be out of your room and talking to others

knee surgery post op and diaphoretic and visual hallucinations

obtain vital signs

health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN

pancreatitis

borderline personality disorder self-inflicted lacerations on abdomen

perform the dressing change in a nonjudgemental manner

Anger Management Give the client

permission to be angry

Afemaleclientengagesinrepeatedchecksofdoorandwindowlocks.Behaviorthat prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

plan a list of activities to be carried out daily.

Countertransference occurs when a mental health care professional

redirects his or her feelings toward a client or becomes emotionally entangled with a client router transference

A patient who has been on an antidepressant for 2 weeks. What should youwatch for?

suicidal attempts

A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first observe

the client in the chair?

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client • Do you hear voices.

• Do you hear voices.